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RING^A^ORM 



ITS 



DIAGNOSIS AND TREATMENT. 



BINGWOEM 



ITS 



DIAGNOSIS AND TREATMENT 



BT 

ALDEB SMITH, M.B. Lond., F.R.C.S. 

RXSIDBNT MEDICAL OPrXCBR, CBRIST's HOSPITAL, LONDON. 



TfflRD EDITION 

REVISED, AND IN PART RB-WRITTEN. 
WITH ILLUSTRATIONS. 



LONDON 
H. K. LEWIS, 136 GOWEB STREET, W.C. 

1886. ^ 



CeJUL 85 
!H^ , . 

£>cfor2. 



London 

PRINTED BY H. K. LEWIS, 

236 GowER Street. 



PEEFAOE TO THE THIED EDITION. 



In the present edition of this work^ many parts 
have been entirely re-written, more especially the 
diagnosis of ringworm of the body, and the 
treatment of ringworm of the head; the whole 
book has also been thoroughly revised. I have 
endeavoured to make the directions on all points 
more intelligible, and to profit by many kind sug- 
gestions; thus new matter has been added on 
almost every page. A short History of Ring- 
worm, and a reference to the latest experiments 
on the Life History of the fungus will be found at 
the beginning of the book. 

Solutions of parasiticides in alcohol, ether, and 
chloroform, have lately been found very efficacious ; 
also the pure oleates of copper and mercury (Dr. 
Shoemaker^s), which are fast superseding the old 
solutions in oleic acid. Full instructions will be 
found for all the new methods of treatment, in- 
cluding a note on electrolysis for the removal of a 
few isolated stumps. 



VI PEKPACE. 

A new plate (Plate II) has been added^ showing 
the myceliam and conidia on a stump from chronic 
ringworm. 

The book is especially intended to be a concise 
and practical guide to medical men^ both for the 
diagnosis and the treatment of this troublesome 
complaint ; and the wide experience I have had 
must be my apology to them for any apparent 
dogmatism in my remarks, and for — ^what some 
may think — the strong expressions I have used 
with regard to medical certificates. 

In conclusion, I hope this edition will meet 
with as favourable a reception as the two former 
have done. 

ChrisVs HospitaXf London. 
May, 1885. 



PEEFACE TO THE FIEST EDITION. 



Having devoted mucli attention daring the last 
ten years to the diagnosis and treatment of Bing- 
worm^ and particularly of chronic and inveterate 
cases^ I have endeavoured in the present little 
work to give^ as the result of a more than ordinary 
experience of the disease^ some useful and 
thoroughly practical hints on the subject^ especi- 
ally as to the production of Jcerion, the inflamma- 
tory form of the afifection^ and Nature^s method of 
effecting a cure. If this can be produced artifici- 
ally^ a speedy and certain cure is the result. 

Some of the following observations recently 
appeared in the columns of '^ The Lancet; '* and I 
now reprint them, with many additions, and a new 
diagram of a hair recently affected with ringworm^ 
in the hope that they will be serviceable to the 
medical practitioner^ in his endeavours to diagnose 
and eradicate this insidious, and very troublesome 
complaint. 

November, 1880. 



CONTENTS. 



PLATES. 



PLATE I. 



Microscopical appearance of a stamp with the fungus, from 

recent ring^vorm. 



PLATE II. 

A stump from a very chronic case, showing the conidia and my- 
celium down to the bulb. 



PLATE III. 

Portion of a diseased stump from chronic ringworm, highly 

magnified. 



PLATE IV. 
Two stumps from alopecia areata. 

PLATE V. 
Specimen of mycelium, etc., from body ringworm. 



CONTENTS. 



chaptee i. 

Introductoey Remaeks — History — Etiology — 
The Fungus : Life History — Action of the 
Fungus — ^Thb Soil — ^Teeatment. 



Page 
Bingworm caused by a parasite — history — usual causes — 

hair-dressers — hatters — common cause of spread, con- 
tagious nature — essential cause of symptoms is the growth 
of a fungus— proofs — from animals — life history of fungus 
— proofs of non-identity of the fungi in ringworm and 
favus — action of the fungus — the soil— special general 
conditions favouring parasitic growth — the essential 
point in treatment 1 



OHAPTEE II. 

The Different Varieties, and the Diagnosis of 

Ringworm of the Head. 



Diagnosis of recent ringworm — ^recent typical patches — bald 
places — recent pustular ringworm — porrigo— contagious 
impetigo — kerion— position for the examination of the 
head — microscopical examination of stumps from recent 
ringworm — diagnosis of ringworm which has existed some 
time — mistakes in diagnosis — stumps — microscopical 
examination of a stump from chronic ringworm — dis- 
seminated ringworm — diffuse ringworm — chronic pustu- 
lar ringworm— small spots — medical certificates . . 17 



CONTENTS. XI 

CHAPTER III. 

When is Ringworm to be Peonounced Cured? 
How Long has it Existed ? — Incubation 
Period — Amono what Classes is it Pound? 
— Ages — When most Contagious, etc. — Per- 
centage Among Children. 

Page 
When is ringworm cured ? — atrophied stamps — ^how long has 

it existed — diagnosis of chronic ringworn — rate of growth 
— ^incubation period— can a child have ringworm twice ? 
among what classes is it found ? — ages —when most con- 
tagious — ^per-centage among boys and girls — tables of per- 
centage • . . 88 



CHAPTER IV. 

The Diagnosis of Bingworm of the Head from 
Scurf, Pityriasis, Eczema, Psoriasis, Impe- 
tigo, and Pavus — Alopecia Areata : Its 
Nature, and Diagnosis. Mixed cases of 
Alopecia and Ringworm. 



Common mistakes in diagnosis — diagnosis from local scurfi- 
ness — seborrhoea, Ac. — squamous or dry eczema — 
psoriasis — impetigo contagiosa or porrigo — favus — bald 
spots — alopecia areta — differeut opinions on the question 
of the parasitic or non-parasitic nature of alopecia — dia- 
gnosis of alopecia — microscopical examination of stumps 
from alopecia — mixed cases of alopecia and ringworm . 54 



XU CONTENTS. 

CHAPTER V. 

Rengwobm op the Body, the Beard, and the 
Nails, and its Treatment. 

Page 
Tinea oircinata — herpes circinatus — etiology — diagnosis- 
pathology — microscopical examination — uncommon forms 
of body ringv7orm — Indian, BarmesCi Chinese ringworm 
— ^eczema marginatum — tinea oircinata, transmitted from 
animals— diagnosis of body ringworm — ^from seborrhoea 
or pityriasis — psoriasis — eczema — erythema — herpes — 
treatment of body ringworm—when is it to be considered 
cured ? — tinea sycosis — description — diagnosis — treat- 
ment — ringworm of the nails 73 

chapter v[. 
The Treatment of Recent Ringworm of the Head. 

Introductory remarks — ^selection of a treatment — treatment 
when the case is first seen — removal of the bair — washing 
— treatment of very recent ringworm — one or two places 
— chrysophanio acid in chloroform — boracic acid lotion 
— salicylic acid — vesicants — corrosive sublimate — car- 
bolic glycerine — acetic acid — Coster's paste — Goa powder 
and chrosophanio acid — chrysarobin .... 102 

CHAPTER VII. 

The Treatment of Recent Ringworm of the 
Head, when the Disease is not confined to 
A FEW small places: and of Impetiginous 
Eczema and Ringworm. 

Extensive and recent ringworm — boracic acid lotion— thymol 
—epilation by causing dryness of the part — oleate of cop- 



CONTENTS. XIU 

Page 
per — Dr. Shoemaker's oleates — carbolic acid, citxine, and 

sulphur ointments — Goa powder — chrysarobine— salicylic 

add— creasote — sulphurous add — thymol and menthol — 

tincture of iron — turpentine — ^boro-glyceride — ointments 

—treatment when the scalp becomes tender and sore— 

* 

treatment of crusting im|)etiginous eczema . . 117 



CHAPTER VIII. 

The Teeatmbnt of Chronic Binqwobm : st the 
Oleates of Mebcuby and Copper: General 
Directions during Treatment. 

The reason why chronic ringworm is so difficult to cure — 
treatment by boradc add lotion — oleate of mercary — Dr. 
Shoemaker's oleates — treatment by oleate of mercury- 
constitutional effects — oleate of copper treatment — gene- 
ral directions during treatment — ^hair cutting — caps— ap- 
plication of remedies — ^prevention of spreading — washing 
— crusts and scabs — epilation— prerentive lotions and 
ointments — period of treatment— the general health — in- 
dications showing that a remedy is operating beneficially 136 



CHAPTER IX. 

The Artificial Production of Kebion. 

The Tbbathe5T of Cubokic Ringwobic, whebe the 
Disease doss not Extend oteb a Large Extent 
of SubfaoBi and the Tbeatment of Tinea Kebion. 

Kerion — sometimes happens accidentally — may occur spon- 
taneously — Nature's method of effecting a care — ^when 
kerion ought to be produced artifidally — croton oil — 



X17 CONTENTS. 

Page 
directions for unng croton oil— *preeaation8 to be ob- 
served — the great aim of this treatment — the oil getting 
on to the pillow-case — treatment after kerion has been 
produced — treatment of the bald patches — small places 
or isolated stumps re-appearing — ointments, etc., may 
cause kerion unexpectedly — treatment — the parents 
ought to be previously prepared for this result — ^kerion 
resembles the formation of an abscess — croton oil in 
some cases applied repeatedly without producing kerion — 
treatment if a pustular rash only is produced — very rarely 
slight sloughing — distinct bald patch ought never to be left 
— exact description of kerion— not an abscess — ^kerion must 
not be produced indiscriminately — ordinary chronic cases 
can be cured without kerion — a deep pustular rash alone 
is often caused by croton oil — will often cure — ^but cer- 
tainly not all inveterate cases — sometimes a few of the 
follicles become obliterated — ^list of most suitable cases 
in which to produce kerion —a bald place may be left — 
treatment of tinea kerion — incurable cases of extensive 
ringworm 160 



CHAPTER X. 

The Treatment of Disseminated Binowobm. 

Forceps and glass used— method of procedure in disseminated 
cases — treatment with minute drops of croton oil — use of 
the point of a gold needle to press the oil into the follicles 
—treatment with terchloride of antimony — by electrolysis 
— inveterate and incurable cases ; what to do with them 179 



CHAPTER XI. 

General and Constitutional Treatment: Scqrp 

AFTER ElNGWORM : ThE TREATMENT OF ALO- 
PECIA. 



CONTENTS., XV 

Page 
General treatment— disinfectioii — isolation — preventives — 

oonstitationa] treatment — iron, etc. — fat — scurf after 
ringworm — ^its nsual canse and treatment — the treat- 
ment of alopecia 188 



CHAPTER XII. 

RiNGwoBM IN Schools. 

including thb questions of '' cebtificatbs " and 
" isolation :*' obnbral rules to be obsebyed in 
schools: genebal bules to be obsebyed by 
pabbnts: pbecautions to be obsebyed, if a case of 
binowobh appeab in a family ob a school: gen- 
xbal tbeatxent of the ihfectbd gases. 

Qaestions of medical certificates — examinations at public 
schools — ^wfaen cases may be admitted into schools— 
what is to be done with chronic cases with a few stumps 
still remaining — useless to reject disseminated cases 
(under proper treatment), and to admit boys (with 
medical certificates), with large patches of chronic ring- 
worm — children are constantly sent to school with in- 
correct medical certificates, when they are suffering from 
severe and chronic ringworm — suspicious certificates — 
injustice to Principals of schools — succession of out- 
breaks in a school may be due to a boy who is under 
treatment for supposed chronic scurf or eczema — general 
rules to be observed in schools — examinations — separate 
things — ^washing the heads — hair-cutting — general rules 
to be observed by parents — precautions to be observed 
if a case of ringworm appear in a school, or a family 
— isolation — disinfection — washing — examination of the 
supposed healthy children — treatment if the disease 
spread — preventives — greasy applications — dietary — 



XVI CONTENTS. 

Page 
cubic space — ventilation, etc. — ^nurses — useless to take all 

these precautions, unless all chronic and disseminated 

cases are detected and treated— general treatment of the 

infected cases — isolation — linen — hair-cutting — ^when 

may a child mix again with the healthy ? — can children 

under efficient treatment give the disease to others? — 

question of children attending school with uncared ring- 

worm — question of the age of the pupils .... 194 



PBESCBIFTIONS. 

For body ringworm — ^recent ringworm ~ and chronic ring- 
worm — ^preventive lotions and ointments — for alopecia 
areata 209 

Index .219 



DESCRIPTION OF PLATE I. 

The projecting part of a broken hair or stump^ 
removed from a recent patch of ringworm, showing 
the masses and strings of conidia (tricophyton 
tonsurans) ; many conidia, in groups or strings, 
may also be seen floating about the field, together 
with oil-globules, epithelial cells, and debris. 
{Vide p. 25). 

(Hartnack, oc. 3, obj. 7, magnified about 300 
diameters). 



r 



DESCRIPTION OP PLATE II. 

A stump (shortened to save space) taken from 
a case of chronic ringworm, of nearly three years' 
duration ; showing the rows of conidia, even down 
to the bulb, and the appearance of the extremity 
of the stump, where it has been broken off, and 
frayed out. It also exhibits a most extensive 
implication with the fungus ; rows upon rows of 
conidia being seen, running parallel with the fila- 
ments of the hair. In parts, the whole thickness 
of the hair seems to be filled with these rows of 
conidia, giving it the appearance of fish^roe. A 
network of mycelium may be observed on the 
lower part of the shaft, by the bulb. Some oil- 
globules may also be seen about the free end. 
(Fide p. 83). 

(Hartnack, oc. 4, obj. 7, magnified about 450 
diameters). 



DBSCEIPTION OF PLATE III. 

Portion of a highly magnified stump^ from a 
case of chronic ringworm, showing tlie masses and 
strings of conidia, with the nuclei. At some parts^ 
nests of conidia are to be observed in the sab- 
stance of the hair, splitting the filaments ; and at 
one point the shaft is seen to be distended and 
ruptured, with the filaments and conidia protrud- 
ing. A few oil-globules are also to be observed. 
(Vide j>. 33). 

(Hartnack, oc. 4, obj. 9, magnified about 860 
diameters). 



DESCRIPTION OF PLATE lY. 

Two stnmps (shortened to save space)^ taken 
from a case of alopecia areata; showing the entire 
atrophied roots, and the shafb dilated and 
darkened in places, forming bulbosities, which are 
deeply pigmented in the centre, with a large 
amount of dark granular matter. The free end is 
observed to be club-shaped, more opaque and 
pigmented, and exhibits a cluster of fibres radi- 
ating outwards in a brush-like form. One of the 
stumps is seen to be half-broken, and bent over, 
at one of these pigmented bulbosities. (Vide 
p. 70). 

(Hartnack, oc. 8, obj. 7, magnified about 800 
diameters). 



DESCRIPTION OF PLATE V. 

The trichophyton^ as seen among the epidermic 
scales in body ringworm, consisting chiefly of 
mycelium, in long, slender, sharply-contoured 
threads, like ribands, jointed at irregular intervals, 
and branched, forming a net-work. The conidia 
are seen singly, or in chains. {Vide p. 76). 

(Hartnack, oc. 4, obj. 7, magnified about 450 
diameters). 



EINGWOBM 

ITS 

DIAGNOSIS AND TREATMENT, 



CHAPTER I. 

InTBODUCTOET RBMAElf S — HiSTOET — EtIOLOGY — 

The Fungus : Life Histoey — ^Action op the 
Fungus — ^Thb Soil — ^Tebatmbnt. 

BiNGWOBM is a disease of the skin caused by a 
microscopic vegetable parasite ; and the character- 
istic lesions are due to this minute fungus in- 
vading the epithelial layers of the skin^ the hair 
follicles^ and the hairs. The growth which causes 
this very troublesome affection^ belongs to the 
lowest order of plant life^ the fungi or moulds ; 
the same fungus is found both in ringworm of 
the head and the body^ and the two affections are 
essential!^ one. This disease^ which is a very 
common one^ is liable to attack all classes — the 
rich as well as the poor — and is highly contagious^ 
but it is almost entirely confined to children. 

B 



EINGWOBM : IT8 HISTOEY. 



History. 

The history of ringworm is complicated, as 
certain varieties of form of the disease have re- 
ceived a number of designations from the older 
authors.* 

Willan's description in 1817, is the first to which 
it is necessary to refer ; he describes this affection 
and says it is hard to cure, and very contagious. 
Plumbe evinced a more thorough knowledge of 
the disease in 1821, and stated that it took quite 
a different form in the scalp from non-hairy 
parts, and that, on the skin, it coincided with 
the herpes circinatus of Bateman ; that the crusts 
of porrigo scutulata of the scalp when inoculated 
on the skin would produce circles of ringworm, 
and conversely, that from these cutaneous circles 

• Fix, Porrigo scutulata, WUlan ; herpes tonsurans, herpes 
squamosus, Cazenave; herpes circinatus, Ba^^man ; porrigo 
tonsoria, dartre furfurac6e arrondie, Alibert ; tinea tondens, 
squarus tondens, Mahon ; phyto-alopecia, Malmsten; rhizo- 
phyto-alopecia, trichophytie, Gruhy ; dermatomycosis tonsu- 
rans, Kohner ; tinea trichophy tina, tinea circinata, Anderton ; 
trichonosis furfuracea ; porrigo furfurans ; lichen herpeti- 
formis, Divergie; lichen circumscriptus, figuratus, gyratus, 
impetigo figurata, &c. ; Germ,, scherende flechte ; Fr., herpes 
tonsurant ; teigne tondante ; teigne tonsurante. 



HISTORY. O 

pomgo of the scalp could be reproduced. In 1829, 
Mahon again drew attention to the disease, but 
still it was not understood, and was often con- 
fused with other affections of the scalp, as alo- 
pecia, favus, seborrhoea, eczema, herpes, &c. In 
1840, Gazenave noted an affection of the scalp 
attended with loss of hair, broken-off hairs, and 
vesicular eruption extending at the periphery, evi- 
dently spreading among the boys of a school. But 
Gruby, in Paris in 1844, made the discovery that a 
fungus was present in the broken-off hairs, and in 
their root-sheaths; this parasite was fully des- 
cribed by Malmsten, in Stockholm in 1845, and 
it was named by him the Tricophyton Tonsurans. 

In 1854 Hebra mentioned the various forms of 
the disease. After this the significance of the 
newly found parasite was generally acknowledged, 
and there is only one writer* of eminence of late 
years, who has doubted the etiological importance 
of this fungus. During the last quarter of a cen- 
tury many authors have written on the subject, 
especially the late Dr. Tilbury Pox. 

* Erasmus Wilson, Art. Ringworm ; Quain^s Dictionary of 
Medicine^ 1883. 



b2 



BINGWORM: its ETIOLOOt. 



Etiology. 



Ringworm (tinea tonsurans, or ringworm of the 
head, and tinea circinata or ringworm of the body), 
is essentially a contagious disease, and may easily 
be commanicated from one child to another by 
direct contact, or by caps, comforters, brushes, 
combs, towels, linen, &c. 

There is no doubt that hair-dressers often — 
though unwittingly — propagate ringworm; for 
children, suffering from this disease in every 
stage, are taken to hair-dressers to have their hair 
cut; and if the next customer happen to be a 
child and the same brush and comb be used, the 
chances of infection are very great. The same 
want of care, on the part of parents and others, is 
seen when children with this complaint are allowed 
to try on several new caps at the hatter's. There 
is but little doubt ringworm is often propagated 
by these means, as well as by children being al- 
lowed to play and romp together. This allows of 
direct contact of heads; therefore children with 
uncured ringworm should never be allowed to 
romp or play with those who are free from the 
disease. 

The most common cause of ringworm spreading 
is the accidental contact of healthy children with 



ETIOLOGY. 5 

the heads of, or with infected articles belonging 
to boys or girls, with chronic, and often unJcnown 
and untreated, varieties of the disease, which are 
every day mistaken for chronic scurf or dry 
eczema. This matter will be fully considered 
further on. 

Yet we cannot deny the possibility of the trans- 
mission of the conidia through the air, as the 
late Dr. Tilbury Pox found the fungus-elements 
in abundance in the dust deposited from the air 
of a ward in which ringworm cases were located. 

The contagious nature of the affection has been 
fully demonstrated by experiments, as well as 
by clinical observation. As to the nature of 
ringworm, Dr. Fox says: — "The arguments in 
favour of the assertion that the growth of the 
parasite is the essential cause of the inflamma- 
tory symptoms and the disorganised state of the 
hairs in ringworm are unanswerable. I will 
mention but one or two. No such textural 
alteration as is present in the hairs in ringworm 
is ever produced except by the attack of the fun- 
gns upon them; with the destruction of the 
fungus the disease at once ceases ; parasiticides, 
if they reach the fungus, speedily cure the dis- 
ease ; and lastly, the fungus can be shown to be 
a vegetable structure by artificial cultivation. 



b bingwobm: its btiolooy. 

which is impossible in the case of degenerate 
animal stmctore ; and by chemical manipulation/'* 

There is no doubt that ringworm is sometimes 
communicated to man from the lower animals^ 
but this source of infection I believe to be an ex- 
tremely rare one for ringworm of the head. The 
ringworm so produced is usually tinea circinata, 
and^ therefore^ found on the arms or bodies of 
those attending to diseased animals. 

Kaposif says^ '^ The fact that tinea tonsurans 
may be transmitted accidentally^ or purposely^ to 
man from the animals named (viz. horses^ cattle^ 
dogs^ cats^ and rabbits) and^ in part^ vice versd^ 
has been so thoroughly established that it would 
be superfluous to adduce here any further special 
observations^ such as we ourselves have had plenty 
of opportunity of making." 

Bingworm may attack any part of the body^ 
but it is much more difficult to eradicate when it 
exists on the head. Bingworm of the body^ as it 
is generally seen in England^ is readily cured by 
almost any parasiticide^ because the essential 
cause of the mischief^ vk. the fungus^ lies close 
at hand, and can easily be destroyed. Ringworm 

* Lecturer on Ringwormy Dr. Tilbury Fox. 
f Hebra, Diseases of the Skin, Kaposi, vol. v., p. 218. 
New Sydenham Society, 1880. 



THE FUNGUS. 7 

of the head is very rarely contracted after the age 
of puberty^ but cases have been seen in the 
adult j in adults it is more often found affecting 
the hairs of the beard^ than the head^ producing 
parasitic or tinea sycosis : on the other hand^ 
infants are rarely affected. Ringworm of the 
body may develop at any age^ though it is much 
more common among children. If it occur in 
adults^ it is generally observed on the hands or 
arms of those attending children afflicted with the 
complaint. 

Tinea tonsurans and tinea circinata differ only 
as regards their locality. The former often infects 
the body^ producing patches of tinea circinata; 
at other times a patch of tinea circinata may 
spread and involve the head. 



The Fungus: 

UFB HISTOBY. 

The question of the exact nature of the fungus 
is a difficult and intricate one to answer. Kaposi 
says: — 

" It will be seen that^ in spite of the numerous 
observations on record of attempts at cultivation^ 
we are far £rom being able to determine the pro- 



8 eingwoem: life histoey 

per relationship of the fungi met with in well- 
established parasitic dermatoses to one another or 
to the mould fungi^ or^ lastly^ the position they 
should hold among the numerous members of the 
class of thallophytes. If, therefore, some patholo- 
gists hold the opinion expressed by Hebra of the 
identity of favus and tinea tonsurans to be true, 
and even include pityriasis versicolor also, it is 
important that it should be understood that they 
are not at all supported by scientific mycology at 
the present time. It follows necessarily that 
we must, for the present, regard the fungi met 
with in the dermatomycoses as specific indivi- 
duals, that they strictly belong to individual forms 
of skin disease, and we must do this so long as 
their relationship with other forms is not demon- 
strated/'* 

But Neumannt referring to tinea tonsurans, re- 
marks : — '^ The results of my experiments in the 
generation of this parasite confirm the observations 
of Hebra in so far that herpes tonsurans and favus 
can be produced by one fungus, and that the 
penicillium/' Dr. LiveingJ says : — " An able 

* Hebra, Diseases of the Skin, Kaposi, vol. v., pp. 114 
to 138. New Sydenham Society, 1880. 

\Arch,f, Dermatol, u. Syph,, 1871; ** Lehrbuch derHaut- 
krankheiten" 1871. 

X Handbook of Skin Diseases^ 1880, p. 307. 



OP THE FUNGUS. » 

English botanist confirms this view, and tells me 
that he is quite unable to distinguish the parasite 
of ringworm from penioillium glaucum/' 

Grawitz* in 1877, Atkinsont in 1878, and 
Thin J in 1881, made and recorded experiments 
on the cultivation of the fungus; and in 1883, 
a paper was read " On the cultivation and life his- 
tory of the ringworm fungus," before the Royal 
Microscopical Society, § by Mr. Malcolm Morris 
and Dr. G. 0. Henderson, recording numerous 
experiments both of their own and of previous 
investigators, and giving excellent plates of the 
fungus in different stages of development. The 
following is extracted from their paper. 

After 12 hours^ cultivation in gelatine peptone, , 
the spore became swollen and pear-shaped. In 
24 hours the protrusion was elongated into a 
retort -shaped body. In 48 hours the filament 
was 0.9 mm. long, on the fourth day branching 
occurred, and by the seventh a dense network 
was seen. Spores only formed when the filaments 
reached the air ; and these spores placed in fresh 

• Firchou^s Archiv, LXX., 1877. 
f New York Med, Jour., 1878. 
X Proc. Royal Soc, 1881. 

§ Printed in the Journal of the Society, Ser. II., vol. iii., 
p. 329. 



10 BINGWORM AND FAVUS : 

peptone grew in exactly the same way as the 
primary spores. 

They also prodaced^ when placed on the human 
skin^ a crop of itching papules on the third day^ 
and about the sixth day they coalesced to form an 
erythematous patchy the centre of which faded and 
desquamated^ while the margin spread centrifu- 
gaily. It is also stated that : — " The branching, 
septa formation, and fructification are identical 
with those of Penicillium." 

Mr. Morris informs me that he was unable to get 
the same results in his experiments with spores 
from favus, and is of opinion that the two fungi 
are distinct. 

Dr. Duhring* says : — " The Achorion Schonleinii 
(the fungus of favus) is a distinct variety of fungus, 
and is capable of giving rise to one form of disease 
only, namely, tinea favosa." 

Again I quote the following : — 

"The clinical proofs of the non-identity of the 
two diseases (tinea tonsurans and favus) are found 
in the fact that pure ringworm occurs in thousands 
of cases without any development of favus ; in the 
highly exceptional simultaneous or consecutive ap- 
pearance of true ringworm in cases of favus ; in 

* Diteasei of the Skin, by Dr. Duhring, Philadelphia, 1881 . 



THE FUNQI ABB DISTINCT. II 

the frequency of the former in communities and 
the rarity of the latter; and in the varying rela- 
tions of their comparative frequency both in differ- 
ent countries and in cities and rural districts ; in 
the prevalence of ringworm of the scalp in orphan 
asylums for years continuously, without the pro- 
duction or transmission among the inmates of any 
parasitic affection other than itself; in the ease 
with which the one, and the difficulty with which 
the other is communicated ; and in the spontane- 
ous transmissibility of both forms from man to the 
domestic animals, and back again through several 
hosts to the human subject — their individual 
identity being without exception preserved mean- 
while. These, and other facts which might be 
mentioned, would seem to be conclusive in this 
matter. The results of inoculation and artificial 
cultivation, too, support the view of the specific 
individuality of these affections/'* 

There is no doubt, in my mind (with which view 
Dr. Liveing agrees), that the fungi found in the 
parasitic diseases (ringworm, favus, and pityria- 
sis versicolor) are distinct, and that they are of 
primary importance in their etiology. 

* A»hhurtt^8 Encyclopcedia of Surgery ^ vol. ii., p. 657. 



12 BINGWOEM : ACTION OP THE FUNGUS. 



Action of the Fungus. 

When the fungus is first brought into contact 
with, and effects a lodgment on the surface of the 
skin, if the soil be suitable, it commences to grow. 
It then passes between the superficial cells of the 
epidermis, and finding its way into the deeper 
layers, causes irritation, redness, and a certain 
amount of inflammation, with a ring of minute 
papules. These are followed, if the irritation be 
severe, by minute vesicles. As the ring spreads, 
the hypemmia in the centre disappears, and de- 
squamation follows. 

If the part is hairy, the hair-follicles and hairs 
are quickly involved. The mycelium threads and 
conidia soon penetrate between the hairs and the 
inner root-sheaths, and also into the substance of 
the hairs. The fungus advances deeply into the 
follicles, ramifying up and down between the fibres 
of the hairs, and separating them. It thus in- 
terferes with their nutrition, and renders them 
swollen, lustreless, opaque, dry, and brittle. 
Therefore they break off close to the surface 
of the scalp, as if ^' nibbled,'^ forming stumps 
(described page 31). After some time the fungus 
splits up the hairs, and disorganises them. 



THE SOIL. 13 

These changes take place over more or less cir- 
cular areas^ which vary in size from a split pea to 
the palm of the hand. 



The Soil. 

All children are not equally susceptible to ring- 
worm. A certain unknown condition of the skin 
is necessary for the growth of the fungus^ as some 
children never take ringworm though constantly 
liable to become infected. For it is evident that 
when one child in a family has ringworm and is 
not under any treatment^ the others must be 
exposed to the action of the fungus ; yet^ at times^ 
the disease does not spread. 

This fact is often used as an argument by 
parents^ to prove that their children are not suffer- 
ing from any contagious form of disease^ and that 
they are in a fit condition to enter a school. 

On some the fungus takes but slight hold^ and 
is easily destroyed. Others are extremely sus" 
ceptible ; the disease quickly attacks the follicles 
and the hairs^ and spreads with great rapidity 
although under treatment. Sometimes treat- 
ment even accelerates the already rapid spread 
of the disease^ by producing impetiginous eczema 
with crusts; and^ by means of the pus^ the fungus 



14 BINOWOBM : THE SOIL. 

is carried to more distant and healthy parts. 
This variety is most difficult to manage. 

The difference in these cases must depend on 
some peculiar nutritive condition of the soil or 
material in which the fungus develops, or upon 
some special state of the general health or con- 
stitution. In fact the state of the soil is a most 
important condition : and the rapidity with which 
a small spot of ringworm will spread before it 
comes under efficient treatment, depends chiefly 
upon this peculiar condition of the soil or nidus. 
We generally find that ringworm specially occurs, 
and spreads most rapidly among poorly nourished 
children of a strumous or lymphatic diathesis.* 
And it is often observed that all the children in 
a family of this description, if they become in- 
fected, will suffer severely; evidently showing 
that there is some general condition present fa- 
vouring the parasitic growth. 

Bingworm is also commonly seen amongst those 
who, while they are not decidedly strumous, are 
yet thin and pallid. 

• Mr. M. Morris states — and I fully agree with him — that 
children with very light hrown, golden or colourless hair, 
with light grey or blue eyes, and with fine skin with thin 
epidermis, take ringworm easily, and usually have it severely. 
The Lancet, Jan. 29th, 1881. 



TREATMENT. 1 5 

Most children with chronic ringworm dislike 
fat ; this avoidance of fat in the diet — according 
to Dr. Fox — "has a most potent influence in 
leading to the development of a condition of 
nutrition which is favourable to the occurrence of 
obstinate ringworm." 

But, on the other hand, we constantly see both 
recent and chronic ringworm in those who are 
neither strumous, nor ill-nourished; in fact upon 
decidedly healthy and robust children. This 
leads me still to hold the opinion, that the pecu- 
liar condition which is favourable to the develop- 
ment of the ringworm fungus is unknown. 

Ringworm does not exercise any noticeable 
influence on the general organism or constitution, 
or on the general nutrition of the body. 



Tbeatment. 

It is sm*prising that the results of the treatment 
of ringworm of the head should generally be so 
very unsatisfactory, but such is the fact; for, 
though some cases of the disease are quickly 
cured, yet a very large proportion are allowed, 
through inefficient treatment, or no treatment at 
all, to spread and to lapse into the chronic form 
before the disease is well taken in hand. 



16 bingwobm: its tbeatment. 

It mast always be remembered that we have to 
destroy a microscopic fungus that is rapidly in- 
sinuating itself into the deeper parts of the epi- 
dermic strata of the follicles^ and between the 
fibres of the hairs^ and therefore fast getting out 
of the reach of remedies simply applied to the 
surface of the scalp : and although general and con- 
stitutional remedies are beneficial in the obstinate 
and chronic forms of the disease^ yet the essential 
point to remember is, that the fungus must he des- 
troyed by local applications^ general treatment 
alone being absolutely useless. 

We have a legion of remedies that will kill the 
fungus, but the difficulty is to get them into con- 
tact with it, deeply situated, as it is, at the bottom 
of the hair follicles. 

Eingworm aflecting parts of the body not hav- 
ing deeply-rooted hair is, generally, easily eradi- 
cated j as well as recent cases of scalp disease in 
very young children ; but now and then, although 
good treatment is adopted, the disease will spread. 



DIAGNOSIS OF BECBNT RINGWORM. 17 



CHAPTER II. 

The Different Yaribtibs^ and the Diagnosis of 

Ringworm of the Head. 



Diagnosis of Recent Ringworm. 

It is a great mistake to think that ringworm of 
the scalp nsuallj presents itself to the medical 
practitioner as a red^ roughs and scaly spot^ of a 
decided ring-like form^ almost destitute of hairs. 
The appearance of ordinary ringworm of the skin 
is not so often seen on the head^ as the typical 
recent patches presently to be described. 

At an early stage of the disease^ there may be 
only a very small^ circular, scurfy spot ; containing 
perhaps, hairs more brittle than usual. But as a 
role, if ringworm is observed at its commencement, 
a small ring of minute papules, followed by pin- 
head sized vesicles on a red base, will be seen at 
the circumference of a slightly raised and scaly 
spot. These quickly terminate in desquamation, 
or furfuraceous scales, and the patch rapidly 

c 



18 eingwobm: its diagnosis. 

spreads and soon puts on a characteristic appear- 
ance. Thus the doctor rarely sees the child until 
one or more hairs are broken off. 

The only way to diagnose ringworm before the 
stumps appear^ is to scrape the surface^ and to 
examine the epidermic scales under the microscope 
for the fungus. 

Eecbnt typical patches vary in size. They 
may be only the size of a split pea^ and are rarely 
larger than a five- shilling piece, but two or more 
often join and form extensive areas of disease. 
They are most commonly situated at the vertex, 
or parietal regions ; are more or less circular in 
shape, and of a greyish or slaty colour; they are 
covered with fine, opaque, branny scales or scurf, 
and are more or less bald, with numerous broken- 
off hairs, or stumps. The scalp is slightly raised, 
and the follicles are too prominent, the skin hav- 
ing the appearance of cutis anserina. The surface 
is covered with dry lamellated scales, and here 
and there slight crusts may be observed. Small, 
asbestos, sheath-like coverings, of a dull white 
colour, and composed of epidermic scales mingled 
with fungus-elements, more or less surround the 
base of the stumps. This gives rise to a white, 
frost- like looking surface. Most of the hairs have 
become broken off, and those remaining can usu- 



DIAGNOSIS OF BECENT BINGWOBM. 19 

ally be easily palled away whole, or else they 
break ofif on the slightest traction. The hairs are 
lustreless, and look as if covered with fine dusfc ; 
and, most of them being broken off short as if they 
had been nibbled, the part assumes a stubble-like 
appearance. The stumps are about an eighth of 
an inch long^ of a yellowish or light colour, and are 
thickened, dull, dry, opaque, brittle, and usually 
break on attempted epilation. Some of the hairs 
are twisted, and bent at an angle, after emerging 
from the follicles. These bent hairs are often due 
to a partial breakage, while the complete fracture 
leaves a stump. At other times actual stumps are 
not seen, but shortened, irregular, twisted-looking 
hairs, sometimes lying quite flat on the scalp, and 
of a lighter colour, which, on attempted epilation, 
break off and show the usual fungus. 

The patches are not always circular ; and some- 
times pus is produced which mats the hnir to- 
gether and forms crusts. There is generally some 
itching of the surface, and this may be one of the 
first symptoms of ringworm. 

It is most important to remember, that when 
ringworm is seen in its first stage, there may be 
no broken-off hairs, and they may have a natural 
appearance. The place looks scaly, and the case 
is often supposed to be seborrhoea, or scurf; but 

c2 



20 kinowoum: its diagnosis. 

if tlie hairs be pulled with the forceps^ they are 
nsaally found to be brittle. 

As this is often the first stage of the dis- 
ease^ it is desirable for children^ who are in any 
way exposed to ringworm, to be carefully ex- 
amined twice a week. Such small scurfy patches 
should be recognised as early as possible, as the 
affection can then easily be cured. A case like this 
is sometimes brought under the notice of a medical 
man, who laughs at the idea of the spot being 
ringworm, and advises no notice to be taken of it. 
Thus, the most valuable time for treatment slips 
away. 

Bald Places. — At times, though very rarely, 
we find smooth, shining, bald places, very 
much resembling alopecia areata. Such cases 
may easily be mistaken for the latter disease, but 
the history of the case will help the diagnosis, 
and generally some diseased stumps can be found 
{Vide Alopecia areata). 

Recent Pqstular Ringworm. 

Recent ringworm may become pustular, instead 
of dry and scurfy. This pustular form of ring- 
worm, which is impetigo plus the riogworm fun- 
gus, is a very important variety to recognise, as 



BSOENT PUSTULAR BINOWOBM. 21 

the pustules barst and cause fresh centres of dis- 
ease to be formed on other parts of the head by 
the transplantation of the pus. A contagious 
impetigo, or porrigo, is thus produced : the head 
getting covered with dry yellowish scales and 
crusts, with pus oozing from beneath them, and 
the hair matted by the discharge. If the crusts 
are removed, the ringworm stumps will be found 
in great profusion underneath them. 

This form is usually attended with swollen 
glands about the neck, and constitutional disturb- 
ance. It is rarely seen in the w^ll-to-do, unless 
with children improperly fed and cared for. 

When impetigo is found to spread among chil- 
dren, it may depend on the existence of ring- 
worm ; and may, in fact, be due to ringworm pri- 
marily, and to constitutional causes secondarily. 
In other words, it is a recent, inflamed, and 
pustulating ringworm, which generally spreads 
very rapidly over the head. 

This form of contagious impetigo is a mosfc im- 
portant disease to diagnose, as it may quickly 
spread through a school of young children ; but 
it must not be confounded with impetigo con- 
tagiosa.* 

Becent cases of ringworm, when placed under 

* Fide Chapter III. " Diagnosis of impetigo contagiosa.*' 



22 bingworh: its diagnosis. 

ordinary treatment^ may take on this pustulating 
form^ but this is a rare complication^ unless the gene- 
ral health is bad^ and the child prone to impetigin- 
ous eczema. One of the severest cases of spreading 
pustular ringworm I have ever seen^ came on 
suddenly (without treatment)^ commencing on a 
patch of chronic ringworm^ that had been quies- 
cent and untreated for six months. In a week 
the head was covered with pustular ringworm, 
which spread even to the face and body. In this 
case, the sudden outbreak was evidently due to 
constitutional q^uses, and improper feeding. 

If ringworm become pustular, it must be pro- 
perly treated, as described in Chapter VII., or else 
it will quickly spread over the head, matting the 
hair in the thick crusts. 

A sharp and strong distinction must he drawn 
between this acute, recent, superficial, and crusting 
impetiginous eczema plus ringworm, and kerion. 

Kbbion. 

When deep inflammation of the follicles occurs, 
with the surrounding substance of the corium, the 
part becomes raised, and has the appearance of a 
subcutaneous abscess ; so-called kerion being pro- 
duced. This variety of the disease destroys the 



EESIOX. 23 

fdngus during the acute inflammation ; in fact it 
cures itself^ instead of spreading the complaint^ as 
the superficial crusting inflammation will do. 
Bemedies which produce the latter may cause 
infinite harm. This is well seen in the incautious 
use of croton oil at an improper stage of the dis- 
ease. Notwithstanding all the minute directions 
given about the artificial production of kerion^ I 
sometimes see cases where the oil has been used 
to recent and spreading patches of ringworm^ with 
the most disastrous effect. One or two recent 
places may soon be converted into the superficial 
variety of crusting impetiginous ringworm, and 
the disease be rapidly spread over the scalp, under 
the combined action of heat and moisture. This 
subject is fully considered in Chapter IX. on 
Kerion. 



Bbcsnt bixqwobm generally spreads if not 
actively treated. The spots enlarge, and others 
rapidly appear on other parts of the head. The 
case then usually passes into the chronic, scaly 
variety ; or rarely it inflames and forms pustular 
ringworm; and in very exceptignal cases, it run9 
on into the variety called kerion. 



24 BINGWOBM: ITS DIAGNOSIS. 



Position foe the Examination of the Head. 

Let me mention here^ that one of the best ways 
to examine a child (who is suspected of having 
ringworm) is^ for the medical man to sit well back 
on a wide-seated chair^ so as to have a space be- 
tween his legs on the front part of the chair^ for 
the little patient to sit upon^ with his or her back 
to the examiner. Then^ beginning at the bottom 
of the back part of the head^ the hairs should be 
turned upwards — the wrong way — with a pair of 
forceps, comb, or the fingers, so as to expose the 
whole scalp, little by little. Then any uneven or 
broken-off hairs will stand out, and be easily ob- 
served with the naked eye. 

When the back of the head has been examined, 
the patient can kneel on a footstool with the face 
towards the medical man, or both can stand up, 
while the hair on the front part of the head is 
turned over in the same manner. Any suspicious 
places should be closely scrutinised with a lens. 

These minutiae are mentioned as a considerable 
amount of time may be saved in examining a 
school, if a proper method of procedure be pursued. 



HICBOSOOFIOAL EXAMINATION. 25 



MiOfiOSCOPiCAL Examination of Stumps fsom a 
Case of Recent Binqwobm. 

In examining ''stumps'' for the fungus, it is ad- 
visable to remove two or three with a pair of finely 
pointed forceps, with the assistance of a magnify- 
ing glass, and to place them in a drop of liquor 
potass89, which has previously been placed on the 
centre of a clean glass slide. The thin cover- glass 
should then be gently applied, and the specimen 
left, if possible, for half-an-hour to two hours, in 
order to make it more transparent. The thin cover- 
glass should then be slightly pressed down, so as to 
compress the stump, and spread out the mass of 
conidia. Any excess of liquor potassse should be 
removed with a piece of blotting paper. 

Great care must be taken to obtain a diseased 
stump, or what is more usual, a portion of one, 
and not to remove from the circumference of the 
suspicious place any short cut-off hairs, which, of 
course, will not have any fungus upon them. 

It is essential to have a microscope of the best 
make in order to obtain a good view of the fungus, 
which chiefly consists of spores or conidia ; and 
it is well to magnify them 450 to 900 diameters. 

The Shaft {Vide Plate ,1.) will be seen to be 



26 ringworm: its diagnosis. 

covered in parts with thick masses of conidia^ but 
not to be split up so much in its substance^ espe- 
cially in the part adjacent to the bulb^ as is the 
case after the disease has existed some time 
{Vide Plate II.). The hair often appears opaque if 
•examined too soon after being placed in liq. po- 
tassdd^ and often of a reddish-brown colour^ but 
after a time it becomes more transparent. The 
shaft is seen to be invaded by the conidia^ and 
fiometimes mycelium threads may be observed on 
the surface and penetrating the substance of the 
hair ; but the broken end^ though swarming with 
conidia^ does not appear quite so frayed out as it 
does in Plate 11.^ taken from a case of much longer 
standing. Many conidia, in groups or strings, 
may be seen floating about the field, together with 
oil-globules, epithelial cells, and debris. The 
little masses of regular sized, double contoured, 
and circular conidia, often compressed at the sides 
into an oblong, or hexagonal shape, are very cha- 
racteristic; and show the specimen to be fungus, 
and not simply fat globules. 

The Conidia measure about the -g^^ to the 
s^o of an inch in diameter, and are composed of 
an outer envelope of cellulose, and an inner mem- 
brane or utricle, enclosing granules and a liquid. 
They are not destroyed by the action of liq. potass., 
ether, or chloroform. 



HICBOSCOPICAL EXAMINATION. 27 

If a stump can be wholly removed with the 
balb^ the transparent mycelium threads can usually 
be seen as a network on the lower part of the 
shafb^ near the bulb {Vide Plate II.). When ob- 
served^ they are pale greyish^ sharply contoured 
threads^ with parallel edges^ branched in a forked 
manner^ and jointed at intervals with real dissepi- 
ments. The tubes contain granules and cells and 
terminate in chains of conidia. 

Often^ in cases not under treatment^ masses of 
fungus elements are removed that require teasing 
out with a pair of needles^ before the conidia can 
be distinctly observed under the microscope. 

If the fine epidermic scales are examined, the 
mycelium filaments will as a rule be seen, as well 
as conidia, penetrating between tiem. 

The mycelium threads and the rows of conidia 
invade the hair down to the bulb^ but they do not 
enter far into this structure, as the freshly formed 
cells resist the action of the fungus, till, in their 
turn, they assume the characteristics of the proper 
hair substance. The fungus does not penetrate 
beyond the epidermic strata. In fact it does not 
attack living tissue ; and Dr. Taylor, describing a 
microscopic specimen, says : — " Laterally, the 
spread of the fungus was limited by the inner root 
sheath, with which, in advanced stages, the spores 



28 binqwobm: its diagnosis. 

were in contact. The integrity of this sheath was 
maintained^ even when the follicle was choked 
with spores. The outer root sheath never showed 
any traces of fangus^ nor did the follicle walls^ the 
subcutaneous tissue^ cutis^ and mucous layer of the 
epidermis/'* 

* For further information on this suhject, vide Hehra, 
'* Dueates of the Skin " Kaposi, p. 210, New Sydenham Society, 
1880. Also, '* On the condition of the skin in tinea tonsurans,^* 
hy Dr. Thin, Med. and Chir. SoCy March 26tb, 1878. 

And " On the condition of the skin in tinea tonsurans/* hy Dr. 
Frederick Taylor, Med, and Chir. Soc.^ Novemher 13th, 1878. 
The suhject was a child who had died of tuhercle, with 
ringworm of the scalp only paitially treated. Reported in 
the medical papers. 

Dr. Rohinson (in the New York Medical Journal for 
March, 1880), describes the appearances found in tinea 
tonsurans, and states that he has found the parasite in the 
coriuni and subcutaneous tissue. He says : — ** The anatomi- 
cal seat of the fungus in tinea tonsurans capillitii is different 
in different cases of disease. It may he seated only in the 
corneous layer, or it may extend even to the subcutaneous 
tissue." 

This observation requires confirmation. 



CHKONIC SQUAMOUS SINGWORM. 29 



Diagnosis op Eingworm which has Existed Some 

Time. 

Chronic Squamous Ringworm. 

In the first place^ I cannot help observing that 
very few medical men^ either in consultation or 
private practice, are aware how extremely diflScult 
some cases of ringworm are to cure ; and the ma- 
jority consider a case well, even when it has as- 
sumed a decidedly chronic state. I constantly 
have boys brought to me on their return to pri- 
vate schools, and very many also on their presen- 
tation for admission to Christ's Hospital, who, 
while bringing certificates from medical men of 
the highest professional standing that they are 
cured of ringworm, and quite fit to mix with 
other children, are still suflering from a severe, 
contagious, and chronic form of the disease ; and 
I have often found on inquiry, that an opinion has 
been formed, and a certificate given without any 
special examination of the scalp, and certainly 
without the help of the lens or microscope. Many 
practitioners imagine that ringworm is cured when 
some of the hair is again growing freely and firmly 
on the part afiected. This is a great mistake, as 



30 bingwobm: its diagnosis. 

some of the most chronic and intractable cases are 
those in which the hair has partially grown again 
on the scurfy patches; but^ on close inspection 
with a lens, some short brohen-off hairs or stumps 
may be seen scattered among the healthy hairs. 

It is impossible to speak too strongly on this 
point, as an outbreak of ringworm in a school is 
often due to the admission into it of an unrecog- 
nised case of the disease. As a rule, the trouble 
arises from a boy returning to school (after he 
has had an attack of ringworm on the head) with 
a certificate to the effect that he is cured, when 
in fact he is suffering from a chronic and conta- 
gious form of the complaint ; or, from the entry 
into the school of an entirely unsuspected case ; 
generally a boy, who has had a scurfy patch on 
his head for some time, but who is, in reality, suf- 
fering from chronic ringworm. I shall refer again 
to this most important subject in Chapter XII. 

Speaking from experience, after the examination 
of a very large number of children, both in private, 
and for admission into Ghrist^s Hospital and other 
schools, I have found that in by far the majority of 
cases where a boy has had ringworm on the head 
within a year or two of my seeing him, the disease 
has not been really cured. As a rule, the treatment 
has been continued until some new hair has made 



STUMPS. 81 

its appearance on the patches^ after which it has 
been discontinued^ although many diseased stumps 
remained. When this stage has been reached^ the 
case will often continue in the same chronic state 
— the patches remaining about the same size^ 
getting neither better nor worse — while the little 
patient^ who may be certified as "perfectly well/* 
may be the constant and unsiispected cause of a 
succession of outbreaks of ringworm in a school. 

Besides the usual chronic cases mentioned 
above^ that is^ where there are numerous broken 
stumps to be seen on old patches — where we see the 
scalp covered with scurf or white powdery scales, 
while the hair is thin, dry, and lustreless — we some- 
times find that the stumps have been rubbed down 
by friction, or partially removed by attempted 
epilation, before the examination. Under these cir- 
cumstances, we see the orifices of some follicles with 
no hairs growing from them — a most suspicious 
sign, — and also some black dots. These "black 
dots ^' are the orifices of diseased follicles, in which 
the stumps have been broken off on a level with 
the surface of the scalp by friction ; or are the 
apertures, filled with dirt, left by the retraction 
of the broken and shortened stump into the fol- 
licle after attempted epilation. 

Stumps. — A mistake is often made as to what 



32 BINGWOBM : ITS DIAGNOSIS. 

is intended by the term "stumps/* Healthy 
short hairs from previous cutting, taken from a 
treatep patchy and even hairs half an inch long^ 
have often been sent to me as " stumps ** to be 
examined for fungus. 

Stumps are diseased hairs^ broken off near the 
surface of the scalp. They are very brittle, and 
almost always break off short on attempted epila- 
tion. They are more or less impregnated with the 
ringworm fungus, which renders them fragile. 
Combing or brushing the hair causes the stumps 
to break off repeatedly; and the small detached 
pieces, being brought into contact with the heads 
of other children, are the usual vehicle by means 
of which the disease is spread. 

Stumps in chronic cases are, at times, ex- 
tremely difficult to find, as they may be hidden 
among the long hairs on a scurfy patch, or under a 
little scale or scab. The only way to detect them, 
when few in number, is to have a good lens and 
a pair of fine-pointed forceps {Vide Chapter X.), 
and then, in a good light, to most carefully ex- 
amine any suspicious spot, pulling away with the 
forceps any scab or crust. 

Then the stumps will be seen just protruding 
through the skin ; often only ^ of an inch long. 
On carefully seizing this projecting point with the 



MICROSCOPICAL EXAMINATION. 83 

forceps^ and using gentle traction^ the stump may 
come away^ but it will usually break off about 
\ of an inch in length, leaving the bulb, and part 
of the shaft, behind in the follicle. It is this 
minute bit of broJcen-off hair that should be ex- 
amined under the microscope. 

Microscopical Examination op a Stump prom 

Chronic Eingworm. 

Upon examination {Vide p. 25) the portion of 
broken hair will be found to exhibit a most ex- 
tensive implication with fungus, even down to the 
bulb of the hair, if that part happens to be ex- 
tracted. Eows upon rows of conidia, or spores, 
like strings of beads, are seen running parallel to 
the filaments, splitting the substance of the hair, 
and causing it to appear thicker than usual. 
Where the disease has existed some little time, 
the whole thickness of the hair seems to be filled 
with these rows of conidia, which give it the ap« 
pearance of a solid mass resembling '' fish-roe " 
(Fide Plate II.). At some parts, nests of conidia 
are seen in the substance of the hair. And now 
and then a hair may be seen to be distended and 
ruptured along its shaft, the filaments with conidia 
protruding at these points {Vide Plate III.) ; and 

D 



34 DISSEMINATED BINGWOBlf. 

in some cases the fungus- elements are so abund- 
ant as to completely disintegrate the hair. The 
free end of the broken stump possesses a jagged^ 
stubble-like^ frayed-out extremity. Between the 
filaments of the faggot-like end many conidia are 
seen. 

If the stump has been wholly removed^ a net- 
work of mycelium threads can generally be de- 
tected on the lower part of the shaft, near the bulb, 
and the mycelium may be seen penetrating be- 
tween the fibres of the hair {Vide p. 27, and 
Plate II.). 

"Chronic," or "disseminated" cases, with 
stumps hke these, have certainly existed for some 
months, or very likely for a year or two ; and 
may have given the disease to many other mem- 
bers of a family, or to the other boys in a school, 
while all the time they have been considered to be 
suflTering from chronic scurf or eczema, or thought 
to be free from all disease. 

Disseminated Bingworm. 

Especially would I call attention to a variety I 
call " disseminated ringworm " — one rarely dia- 
gnosed, and the most chronic and difficult to cure. 
The hair is found to be growing freely and firmly 



CHRONIC PUSTULAR RINGWORM. 35 

all 07er the head ; there are^ perhaps^ no patches to 
be seen now^ althoagh probably they have existed 
at an earlier stage of the disease ; the skin ap- 
pears generally healthy^ and perhaps almost free 
from scurf: but numerous isolated^ and generally 
thickened stumps^ or groups of stumps^ or black 
dots^ are seen here and there^ often scattered all 
over the scalp. This variety is almost always over- 
looked, and can only be detected by very careful 
examination. 

Diffusa Bingwobm. 

A very chronic form, " diffuse ringworm/* is 
also sometimes seen, in which there are one or 
more large irregular patches, often extending 
nearly all over the scalp. The surface is very 
scurfy, and very many of the long hairs have grown 
again, but numerous stumps are to be seen in 
every direction. This variety is constantly over- 
looked, or mistaken for seborrhoea or chronic 
squamous eczema ; but it can always be diagnosed 
by the stumps. Gases are even found where the 
entire scalp is affected. 

Chronic Pustular Bingworm. 

Chronic ringworm may also occur in the form of 
pustular spots, with a certain amount of redness 

D 2 



S6 bingwobm: its diaqnosis. 

and crusting aroand^ and with a stump existing 
in the centre of each spot. This appears to be 
Nature^s effort to get rid of the stump^ and can 
be successfully imitated by treatment. 

Small Spots. 

Sometimes chronic ringworm may exist, without 
apparent change, for months or even years, as a 
single spot, or in spots so small that they are not 
noticed, even by 'professional men, with numerous 
long hairs and only a few stumps. Ofben ten 
minutes or more has to be spent in examining a 
child^s head before any stumps can be detected. 
I have known an outbreak of ringworm in a school 
to be caused by a chronic spot not larger than a 
split pea ; and where only a few stumps could be 
found, on close examination with a lens. 



But apart from these chronic varieties, some of 
which I fully own are exceedingly difficult to dia- 
gnose, I have often had children sent to me certi- 
fied as cured by medical men, when typical patches 
of ringworm were to be seen, as large as five- 
shilling pieces. The places have even been itching, 
and covered with very short, broken, dry, opaque. 



SMALL SPOTS. 37 

and twisted hairs^ looking as if they had beeu 
'^ nibbled off; " frequently of the asoal yellow, or 
ash-grey colour, and with fine, opaque, branny 
scales, or scurf. These facts show that some 
medical men have no idea what ordinary ringworm 
is like ; and even, when these appearances were 
pointed out to them, they affirmed that the disease 
was dried up and cured, and that the child was 
quite fit to mix with other children.* 

The occurrence of the short, nibbled off stumps 
is most characteristic, and with ordinary precaU' 
tions no mistake in diagnosis ought to he made. 

• riV/<? Chapter XII. upon " Medical Certificates." 



38 WHEN IS BINGWOBM 



CHAPTER. III. 

When is Ringwoem to be Pbonounckd Cubed ? — 
How Long has it Existed? — Incubation 
Pebiod ? — Among What Classes is it 
Found ? — Ages — When Most Contagious, 

ETC., etc. — PeB-CENTAGB AMONG ChILDBEN. 

A medical man should not consider a case of 
ringworm to be cared, nor certify that a child is 
fit to retam to school and mix with other children, 
unless he has most carefully examined the whole 
scalp in a good light, and scrutinised any suspi- 
cious scurfy spot with a lens, and is certain that 
there are no broken-off stumpy hairs to be seen (or 
even the black dots before mentioned, p. 31) giving 
evidence of the ringworm fungus when carefully ex- 
amined under the microscope*. Sometimes it is 

• In " ^ Code of Rules for the prevention of Infectious 
and Contagious Diseases in Schools, being a series of Resolu- 
tions pcused by the Medical Officers of Schools Association in 
January, 1885,*' published by J. and A. Churchill, the fol- 
lowing definition, as to when a pupil may return to school 
(after having had ringworm) will be found :— 

** RiNOWOBM — when — the whole scalp having been exa- 



TO BE FBONOUNCXD CUBED? 39 

extremely difficalt to detect the stumps when only 
a few exists and it may take ten minutes or more 
to examine one head. It is important to remember 
that^ because on a superficial examination we can- 
not detect any stumps^ we have no right to con- 
clude the7 do not exist. Sometimes the attention 
is directed to the short hairs round a treated patch 
(caused by the hair having been cut oS), instead of 
to the diseased stumps^ which are frequently con- 
cealed by the healthy hairs^ and only protrude 
about a sixteenth, or even a thirty-second part 
of an inch. In fair-haired children, and recent 
cases, stumps are often of a lighter colour than 
the rest of the hair, while they are commonly black 
in chronic cases with dark hair, 

mined in a good ligbt, and any suspiciouB spot Bcrutinised 
with a lens — no broken-ofF stumpy hairs (which give evi- 
dence of the ringworm fungus when carefully examined 
under the microscope) are to be detected. 

It is sometimes considered that ringworm is cured when 
the hair commences to grow on the diseased places, but this 
is a mistake, for it frequently happens that diseased broken- 
off hairs remain ; and the disease may thus exist for months 
or years. It is oflen very difficult to detect the short stumps 
which protrude only a sixteenth or an eighth of an inch ; 
and it is quite useless to examine short cut-off healthy hairs 
from a suspicious spot, under the microscope, for the ring- 
worm fungus.** 



40 binqwobm: when cubbd. 

As long as any diseased stumps remain— and 
they may exist for years — ringworm is not cured; 
and it may continue stationary, or spread again ; 
and^ what is of more importance^ the child may 
give the affection to other children. 

If all the hair-bulbs could be extracted together 
with the upper part of the stumps^ the disease 
might be considered cured after epilation; but 
some of the stumps are almost certain to break off^ 
allowing the lower parts and the bulbs (which of 
course contain the fungus in an active state) to 
remain behind in the follicles^ out of which the 
diseased hairs will not protrude again for a week or 
two. The mere fact of a stump breaking off, 
shows that it is brittle through the action of the 
fungus. It constantly happens that a doctor re- 
moves, as he thinks, all the stumps from a 
patch, and certifies the case to be cured. But if 
the place be watched a few weeks, the stumps will 
probably appear again. In fact, it is extremely 
difficult to certify that a child who has recently 
had ringworm, is absolutely well. Time after time 
stumps will reappear here and there, breaking off 
when an attempt is made to extract them ; and a 
few may continue to reappear for months, and to 
defy all attempts at their destruction, after the 
case in other respects seems cured. Even special- 



ATBOPHIED STUMPS. 41 

ists may be deceived^ and after putting a strong 
caustic on a patchy and thus getting a bald place 
apparently quite free from broken -off hairs^ they 
may certify the case to be well ; but after a week 
or two^ up come the stumps again^ and prove the 
incorrectness of the certificate. A bald patch 
should^ therefore, never be considered free from 
disease until the new downy hair is growing freely 
from all the follicles, without a single stump or 
black dot to be detected with a lens. 

It is very important to remember that the protrud- 
ing part of a stump may not contain fungus, through 
active treatment, and yet the root part which re- 
mains in the follicle may be saturated with it. 

Atbophied Stumps. — Sometimes, especially after 
the head has been shaved, there are a few atrophied 
stumps to be seen. 

These short hairs are due to some of the hairs 
not growing beyond the length of an ordinary 
diseased stump, after they have been cut off close 
to the scalp. They are to be seen (usually over 
non- affected portions of the scalp) duriug the 
treatment of some cases of ringworm, and are 
often thought to be diseased stumps; but the 
diagnosis is very easy, as these short little hairs 
easily come away entire when extracted, instead of 
breaking off short like diseased stumps. They 



42 BINQWOBU : DIAGNOSIS OF ATROPHIED STUMPS. 

have small atrophied roots, and show no fangas 
under the microscope^ the ends being sharp cut 
(from shaving) or blunt^ and often pigmented; 
the shaft being of the normal^ or less than the 
normal thickness. 

In chronic cases of months or years duration^ 
the diseased stumps undergo some fatty degene- 
ration and disintegration^ and thus many small 
oil- globules are seen in and about them^ as well as 
conidia; but small oil-globules on a normal hair 
or atrophied stump must not be mistaken for 
conidia. To a practised eye there is no difficulty 
in diagnosing between atrophied and diseased 
stumps. The regular^ equal-sized^ and bead-like 
arrangement of the bright and circular conidia, 
with their double contoured outline and nuclear 
contents, on or in the substance of the hair, can- 
not be mistaken when once seen. Ether will also 
distinguish oil-globules from conidia, by dissolv- 
ing the former; again the fractured, faggot-like 
appearance of the broken end of a diseased stump 
is most characteristic. 

If a doubtful case has to be examined, where 
there are a few broken-off hairs which appear to 
show circular dots of fungus under the microscope, 
the best plan to adopt is to wash them well with 
ether. This can easily be accompUshed by pro- 



HOW LONG HAS IT EXISTED? 43 

cnring a glass slide^ with a small circular cavity 
groand in its centre. Then the stumps can be placed 
in it^ a few drops of ether dropped on to them^ and a 
thin glass cover applied. When the ether has 
evaporated^ this process can be repeated two or 
three times. And^ finally^ the stumps should be 
taken^ with a fine pair of forceps, or a needle^ out 
of the liquid ether^ and placed in a drop of liq. 
potassse on a glass slide, and examined in the 
usual manner. 



How Long Has This Eingwoem Existed? 

This is a question often put to the medical at- 
tendant, and one which it is extremely difficult 
and almost impossible to answer. 

I am positive that a ringworm on the head, the 
size of a sixpence, can develop in forty-eight 
hours; and increase to the size of a florin in 
another twenty-four hours, because I have actually 
seen ringworm grow at this rate. But this is 
certainly not the usual rate of progress. Eing- 
worm generally develops much more slowly than 
this ; yet there is no doubt that a moderate sized 
patch may appear in a few days. 

It cannot, on the other hand, be said how long 
it has not existed ; for the place may spread very 



44 CHRONIC bingwobm: its diagnosis. 

slowly^ and remain almost in the same state for 
weeks^ or even months. Again^ it is most diffi- 
cult to give any decided opinion as to the length 
of time a patch of ringworm must haye existed, 
though an experienced eye can generally guess 
the probable existence of the case. 

Chronic ringworm can be recognised by the 
characteristics already given in the Chapter cm 
Diagnosis, especially by finding a scurfy spot with 
long hairs growing freely and firmly upon it, and 
yet a few stumps, which are so rotten that they im- 
mediately break off short on attempted epilation, or 
perhaps only black dbts, (hidden by the long hairs). 
Then, under the microscope, we often find the 
" fish-roe " condition of the stumps before men- 
tioned, with nests of conidia in the substance of 
the hair, often completely disintegrating it {Vide 
Plates II. and III.). 

Cases like these must have existed some time; 
probably for many months, or possibly for years. 

I remember one inveterate case that resisted all 
treatment for nine years, and though the patient 
was eighteen when I last saw him, he still had dis- 
seminated ringworm; and another disseminated 
case (lately under my care) had been treated by 
many medical men for a period of eight years 
without being cured. 



INCUBATION PERIOD. 45 

It is impossible to say how long even a small 
spot of chronic ringworm may not have existed^ as 
it may have remained in a latent state^ for months 
or even years. 

The rate of growth and rapidity of reproduc- 
tion^ are very different in individual cases. If the 
fungns spreads slowly^ it indicates only a slightly 
favourable soil and it can then — ^in its early stage 
— often be qaickly eradicated; but if it grows 
rapidly^ it is due to the general nutritive condi- 
tion furnishing a favourable nidus : it is then most 
difficulty and sometimes impossible to arrest its 
course ; the increase in the rate of growth of the 
fungus being greater than can be counterbalanced 
by rubbing in parasiticides. 

Dr. T. Fox says : — " Ringworm is obstinate in 
proportion as this or that patient offers a favour- 
able soil in his textures for the growth of the fun- 
gus or parasite." 

Incubation Period. 

The period of incubation of tinea tonsurans is 
most uncertain. There is no doubt that a small 
recent ringworm may form on the scalp in a very 
few days from the implantation of the fungus^ but 
it is difficult in most cases of ringworm to tell the 



4'6 POSSIBLE TO BA7E BINQWOBM TWICE. 

day OD which this happened^ and also the number 
of days the disease has existed before it has been 
discovered. 

Mr. Morris' experiments prove that^ after spores 
have been placed on the human skin^ a crop of 
itching papules may form on the third day, and 
that by the sixth day they may have coalesced to 
form an eiythematous patch of weU-marked ring- 
worm.* But there is also no doubt that the fun- 
gus may not find a very suitable soil, and thus 
may lie latent for some time, or grow very slowly : 
so that it is generally impossible to say, with any 
certainty, how long the incubation period of any 
given case of ringworm has been. 



Can a Child have Binqwobm Twice? 

This is a question sometimes asked, as it is 
thought by some people that one attack renders a 
child safe from anothef . This is a mistake, as 
it is perfectly well known that one attack of this 
affection in no way protects a child from a future 
one; and children have often been known to have 
ringworm more than once, especially on the body. 

* Journal of the Royal Mieroseopieal Society, Ser. II., 
vol. iii., p. 329. 



AMONG WHAT CLASSES FOUND? 47 

But many cases of so called fresh development 
of ringworm of the head^ are simply dae to the 
original disease having never been completely 
cored. Ringworm may remain quiescent for some 
time^ and be considered to be well^ and then 
break out again and spread. Therefore^ if a child 
has formerly had ringworm of the head and has 
been supposed to be cured, and again presents 
evidence of having recent ringworm ; it is much 
more likely to be due to some old stumps having 
been left (thus causing a fresh outbreak of ring- 
worm), than to the child having retaken the dis- 
ease from some one else. 



Among what Classes is it Found? 

Ringworm is seen in every grade of society, 
and certainly is not limited to the middle and 
lower ranks, but it is especially frequent amongst 
the children of the lower orders that attend 
school. 

There is but little doubt about there being a 
very large per-centage in many of the Board and 
Elementary Schools, and certainly, the number of 
children that are brought to the out-patient 
rooms of hospitals for treatment is increasing. 



48 AOES: WHEN MOST C0NTAGI0IT8. 

It is a great mistake to think ringworm is dae 
to dirt. Of course neglected children with dirty 
heads are more likely to be exposed to, and to 
take the disease ; bat it constantly occurs in child- 
ren whose heads are kept perfectly clean, and 
where all proper care is taken. No matter what 
precautions are observed with regard to cleanli- 
ness, some of the other children in a school will 
commonly take ringworm if an untreated case is 
accidentally admitted into it, no matter from what 
class of society the pupils be obtained. 

Ages. 

Children under ten years of age seem more 
prone to take the disease than those who are 
older ; and it is very rarely contracted after the age 
of thirteen, and hardly ever seen on the head in 
adults. Again, infants are not often infected. 

About puberty, ringworm is more manageable, 
and generally — even when it has existed for years 
— ^it tends to get well spontaneously soon after 
this period. 

When is it Most Contagious? 

Bingworm is certainly more contagious during 
the primary stage, before treatment, than it is — 



PEB-CEKTAGE AMONG CHILDREN. 49 

when still uncured — after such treatment has been 
discontinued. If left untreated, it is very conta- 
gious^ as the dry particles of epidermis, and 
broken hairs, are easily disseminated through the 
air. 

One of the most important practical questions 
is whether ringworm is contagious when under 
efficient treatment ? This question will be noticed 
in Chapter XII. 



Pes-centaob of Einowobm Cases among Children. 

Very many children in private families and 
schools have this disease without its being sus- 
pected* Strict instructions are issued that child- 
ren who have ringworm will not be admitted into 
Christ^s Hospital; and yet, during the last ten 
years, the average per-centage of boys who have 
had the disease unknown to their parents, or have 
been thought to be well, when /rs< brought here 
for admission, is eight! 

The following table will show the number of 
boys (age from eight to ten years), coming up for 
medical examination here for the first time, and 
the number of oases of ringworm of the head de- 
tected among them : — 

E 



50 



PEB-CENTAOE AMONG BOYS. 



Examination of Bots. 



Christ's Hospital. 



The number of boy8\ 
examined the first 
time, supposed to be 
quite free from ring- 
worm 

The number of ring-1 
worm cases (of the j- 
head) detected . . j 



Age 8 to 10 years — \ 
Average per-centageV 
in lo years . . . . ) 



M 




00 

M 


00 


^ 

** 


M 


M 

s§ 

M 


00 

M 


M 




X93 


xgo 


X74 


187 


205 


217 


183 


179 


z8a 


102 


15 

• • 


20 

• • 


lo 

« • 


19 

• • 


16 

• • 


16 

• • 


16 

• • 


x5 

• • 


X3 

• • 


5 

• • 



Total 

in 

10 years. 



z8i2 



X45 



8 per cent. 



This table proves that eight per cent, of the 
boys^ who have been presented for admission into 
Ghrist^s Hospital during the last ten years (be- 
tween the ages of eight and ten)^ have had ring- 
worm of the scalp ; and also^ that the parents^ as 
a rule, have not been aware of the existence of 
the disease. 

This is an important thoiigh unrecognised fact, 
especially as the boys in this Institution are drawn 
from all quarters of the kingdom^ and from all 
grades of middle-class society. 

During the ten years many of these boys were 
examined and rejected over and over again^ and in 
all there were 217 more postponements during 
this timOj of boys brought up a second^ thirds or 



FEB CBNTAQE AMONG QIBLS. 



51 



even a nintli or tenth time^ and some lost their 
presentations, as they were not free from ringworm 
when ten and a half years old. 



Examination of Gibls. 



Christ's Hospital. 


1878 

10 
3 

• • 


1879 


1880 


x88i 

12 


• • 


1S82 
ZI 

3 

• • 


1883 

8 
z 

• • 


1884 

23 


• • 


Total 

in 

7 years. 


The number of girls 
examined the first 
time, supposed to be - 
quite free from ring- 
worm 

The number of ring-' 
worm cases (of the 
head) detected 

Age 8 to lo years- 
Average per-centage 
in 7 years 


»9 
5 


38 
3 

• • 


IXI 

IS 

Z3'5 per cent. 



With regard to girls, very few have been ex- 
amined, and while mentioning this very large 
average of over thirteen per cent., I feel sure it 
will be much less in the future, as latterly there 
have been so few cases. This is easily accounted 
for by the fact that the girls admitted the last few 
years have come from a far superior class than 
formerly. During these seven years there have 
been 27 more postponements of these cases, when 
brought up a second or more times, and a few 
have lost their presentations. 

These tables fully show that this disease exists 

e2 



52 PER-CENTAQE OF BINQWORM 

to a very large extent in families and among 
school children — many of these boys and girls 
had been attending private schools before the 
examinations — without its being suspected. As a 
rule^ we have found that these rejected cases have 
been formerly treated for the disease^ and that 
treatment had been discontinued because the affec- 
tion was thought to be cured. From personal 
experience I know that children presented for 
admission into other Institutions have ringworm 
in the same^ or even a larger per-centage. It also 
exists largely in many establishments without 
much notice being taken of the matter. 

Some years ago I looked over a boys' school 
(lower middle-class) and found more than half of 
them had tinea tonsurans. Again^ in 1882 I ex- 
amined a Public Institution^ where I found 46 out 
of 47 boys, and 37 out of 45 girls, had ringworm 
of the head !* 

Even schools of the highest class (viz. prepara- 
tory schools for Eton or Harrow) may be more than 
decimated by this scourge. I once examined such 
a school, where more than half the boys had had 

• Fide ** Report of the treatment of a very extensive out' 
break of ringworm of the head, in a school** by Alder Smith, 
British MedicalJoumal, Dec. 16th, 1882. 

Also a Letter on October 7th, 1882. 



07 THE HEAD^ IN SCHOOLS'. . 53 

scalp ringworm during the previous year — though 
each fresh case had been immediately removed — 
and this was solely due to the presence of an un- 
suspected chronic case of the disease which had 
been treated for scurf. Twenty per cent, is not 
an unusual number^ when an outbreak occurs in a 
school from the admission into it of an unsus- 
pected case of chronic ringwcrm. 

Parents and friends will not^ as a rule^ credit 
the diagnosis of inveterate cases^ nor believe the 
time the ringworm has existed, and the time it 
will probably take for its cure. 

They often take the child to another doctor, 
who, knowing perhaps nothing about chronic ring- 
worm, confirms their opinion, and states that the 
case is one of chronic eczema, or scurf. This has 
more than once or twice happened to me, even after 
I had removed stumps from the scalp, and shown 
them to the parents under the microscope, literally 
saturated with the fungus. 



54 SINQWOBM OF THE HEAD. 



CHAPTER IV. 

The Diagnosis of Ringworm of the Head 
FROM Scurf, Pityriasis, Eczema, Psoriasis, 
Impetigo, and Favus — Alopecia Areata : 
Its Nature, and Diagnosis. Mixed cases of 
Alopecja and Ringworm. 

In forming a diagnosis, no reliance whatever 
should be placed on the fact that the hairs come 
out easily on, or around, a suspicious spot, as they 
may do so with equal facility in alopecia, and also 
at times, from any part of the scalp in children 
who are not suflfering from ringworm— especially 
after debilitating diseases. On the other hand, in 
chronic and obstinate forms of tinea they are 
generally firm. This is specially mentioned, as it 
is a very common practice to try the hairs round 
a suspicious spot, and to conclude that the affec- 
tion is not ringworm, or that it is cured, if the 
hairs are firm. 

Another very common error is, to take a long 
healthy hair — or more often one shortened, from 
previous cutting, or shaving— growing close to, 
or even on a patch of ringworm, and, finding no 



DIAGNOSIS FROM SCURF. 55 

conidia on it under the microscope^ to conclude 
the disease is cured. It is worse than useless^ for 
diagnosis^ to look for conidia on healthy hairs 
taken from^ or around^ a treated patch : for^ if 
these are found to be free^ it only leads the ex- 
aminer to imagine the disease is cured. The whole 
attetdionfor diagnosis and prognosis must be paid 
to the short broken- off diseased hairs or stumps. 

If all the fungus be destroyed^ the hairs will 
grow again^ and not break off. The mere fact of 
stumps being seen^ which break off on attempted 
epilation^ is almost positive proof that the disease 
is not cured^ but it is always advisable to use the 
microscope. Sometimes^ after active treatment 
(especially after using boracic^ or chrysophanic 
acid) no conidia can be discovered on the removed 
portion of the broken-off stump^ but if the part 
left in the follicle could be extracted^ it would 
still exhibit the fungus. In doubtful cases/ if 
treatment be left off for a time^ the diseased 
stumps will grow again^ with fungus upon them^ 
and the conidia can be seen under the microscope. 

Diagnosis from Scurf. 

Local scnrfiness^ without stumps^ does not 
necessarily imply ringworm ; but such spots — 
especially in light-haired children^ and certainly 



56 DIAGNOSIS FROM SCURF^ 

if the disease exists in another part of the 
head — are very suspicious, and must be carefully 
examined with a lens^ and the scurf placed under 
the microscope. General scurfiness is not very 
likely to be mistaken for ringworm, but there is a 
variety of local scurfiness of the head which, some- 
times, very closely simulates it. Patches are seen 
where the hair has partially fallen off, having the 
usual scurfy appearance of chronic ringworm ; 
even scabs may exist from slight eczema, or im- 
petigo; and what is more likely to mislead, a 
false appearance of stumps, cavsed by the white 
epidermic scales running up a short distance on the 
shafts of healthy hairs forming asbestos-like sheaths, 
and thus very much resembling ordinary stumps. 
With a lens there is no difficulty in the diagnosis, 
as no broken-off hau's are present. 

But while children, who only have patches of 
scurf, are now and then thought to have ring- 
worm, the reverse error is daily committed, and 
children with chronic ringworm are constantly be- 
lieved to be suffering from simple scurf ! 

I cannot speak too strongly about this matter, 
as hardly a week passes without such cases coming 
under my notice. It constantly happens that 
children with ummred and chronic ringworm have 
been for months, or even years, attending schools. 



AND FBOM SEBOBRHGSA. 57 

and mixiDg in society; and have been often 
treated bj medical men for scurf. Of coarse such 
cases are oflen the cause of outbreaks of ringworm 
in families and schools. 

In all doubtful cases of scurf the diagnosis is 
easy if a careful examination be made with a lens 
for the short broken-off hairs. Sometimes only 
two or three minute stumps can be detected^ even 
after careful examination. But, if there be any 
diseased hairs, the case is still contagious {Vide 
'^ Scurf after ringworm"). 



Diagnosis fboac Steatobrhcea, Seborbhcea, ob 

PiTYBIASIS. 

There is more danger of chronic ringworm be- 
ing mistaken for seborrhoea than the reverse. 
Steatorrhoea sicca is the form usually met with 
on the head or eyebrows, and it is characterised 
by the formation of dry, yellowish scales, which 
fall off as scurf. The hairs are rapidly shed and 
replaced by imperfectly developed ones^ so that 
they are very scanty. Later on changes are pro- 
duced in the epidermis, and the affection goes by 
the name of pityriasis capitis. 



58 DIAGNOSIS, FROM ECZRMA^ 

All these forms of scnrf are easily distingnished 
from ringworm by the absence of stumps, and by 
the examination of any donbtful shortened hairs 
under the microscope. 

Diagnosis fbok Squamous ob Dry Eczema; and 

FROM Psoriasis. 

Squamous or dry eczema of the scalp is rarely 
thought to be ringworm, but chronic patches of 
the latter disease are constantly mistaken for 
eczema, and certified to be non-contagious. This 
mistake is frequently made by medical men over- 
looking the minute stumps, or black dots. 

Many points of difference are given in the text- 
books, but the only one of practical importance is 
the absence in this disease of any characteristic 
stumps on the scurfy patches. 

Psoriasis must also be diagnosed from ring- 
worm by the same means ; besides, other patches 
of psoriasis are usually to be seen about the elbows 
or knees. 

Diagnosis from Impetigo Contagiosa. 
Syn. PoRRiGO Contagiosa. 

The word porrigo was used, by the older writers 
on diseases of the skin, as a term for almost any 



AND FBOH IMPETIOO CONTAGIOSA. 59 

eruption on the head; but now it is generally 
restricted to this affection^ which is a form of pus- 
tular eczema^ and is spread chiefly by the trans- 
plantation of the pus-cells by the patient's fingers. 
This disease is generally confined to the poor^ and 
badly nourished; and there is almost always a 
defective state of the health, with enlarged glands 
about the neck. Greenish-yellow scabs form, 
with a purulent discharge exuding from under- 
neath them, thus matting the hair together. 

This affection is sometimes thought to be ring- 
worm, but the rapidly spreading form of pustular 
ringworm so closely simalates impetigo contagiosa, 
that it is always desirable to remove a few scabs, 
and to most carefully examine the scalp with a 
lens to see if there ai'O any diseased stumps. In 
fact this is the only means of diagnosis in many 
cases. 

Impetigo of the scalp may be due to ringworm ; 
and this variety of pustular ringworm — consisting 
of isolated pustules with diseased hairs — can only 
be diagnosed from simple impetigo by finding the 
diseased stumps. 

Diagnosis from Favus. 
Favus is a very rare disease in England, but is 



60 DIAGNOSIS FROM FAVTTS. 

more common in Scotland. It is almost exclu- 
sively confined to the lower classes^ and is but 
rarely seen upon the cleanly and well nourished. 
The diagnosis from ringworm is comparatively 
easy^ if the characteristic sulphur-coloured crusts 
have formed. But in its early stage favus is easily 
mistaken for tinea tonsurans. Favus commences 
as small scaly irritable patches; the hairs soon 
lose their lustre^ but they do not become broken 
and twisted at this early stage like the hairs of 
tinea tonsurans^ and therefore they can generally 
be extracted entire. Soon several pin-head sized^ 
pale-yellow, crusts develop round the hairs ; these 
are at first convex, but become concave. When 
these peculiar circular, elevated, friable crusts 
form, hollowed out into the shape of a cup, the 
disease is easy to recognise. 

These yellow cups are as large as a pea, or 
larger, and have one or two hairs passing through 
them. Again a peculiar odour is generally pre- 
sent, like that of mice. If a well-formed hollowed 
crust be removed there is a cup-like depression of 
the skin underneath it. After some time the 
hairs become short, dull, harsh, colourless, and 
sometimes baldness ensues. 

The diagnosis in the early stage, can only be 
made by extracting the hairs. They can generally 



DIAGNOSIS FROM FAVlTS, 61 

be pulled out in the early stage of farms with 
entire bulbs and shafts^ whereas in tinea tonsu- 
rans the stumps break off and leave the bulb and 
part of the shaft behind. If there be any doubt 
about the diagnosis^ microscopic aid should be 
employed. A portion of the crust — which is 
principally made up of the fungus, the achorion 
Schdnleinii — should be placed in a drop of liq. 
potass, on a glass slide, and examined with a 
power of at least 500 diameters. The crust will 
then be found to consist almost entirely of fungus- 
elements, which would not be the case if a pustu- 
lar scab were examined from tinea tonsurans. 
The mycelium threads (which are more numerous 
than in tinea tonsurans), and the conidia in favus 
are slightly larger than those of tinea tonsurans, 
but a very practised eye is necessary to distinguish 
them.* The mycelium threads from favus mea- 
sure from '0023 mm. to "OOSO mm., while those 
from tinea tonsurans measure from *0018 mm. to 

* Kaposi says :*— " T1»e most minute description of the 
favus elements, with all the aids furnished by modern 
science, will not avail to distinguish, conclusively, the favus 
fungus from other dermatophyta, and especially the fungus 
of ringworm, for the simple reason that we have only my- 
celial threads and conidia before us." Fide ** Hehra,^' pp. 
J 64-1 74. 



62 DIAGNOSIS FROM BALD SPOTS^ 

•0026 mm. There is a difference in the conidia ; 
for those of the achorion Schonleinii are more 
ovoid^ and are often elongated^ and contracted in 
the middle; while those of the tricophyton tonsu- 
rans do not assume the manifold forms met with 
in the former fungus. The size of favus spores is 
from -0023 mm. to '0052 mm., while that of ring- 
worm spores is from '0021 mm. to '0035 mm.* 

In the later stages, patches of cicatricial 
atrophy would tend to show the disease had been 
favus. 

Diagnosis from Bald Spots. 

Bald spots from cuts or other injuries are some- 
times thought to be patches of ringworm. They 
are easily diagnosed by the depression of the part, 
the glossy appearance of the skin, and the absence 
of stumps. 

I have seen a bald patch on a boy^s head, pur- 
posely made by pulling out the hair, very much 
resemble ringworm, as it happened to be on a 
scurfy place, but of course it contained no stumps. 

There is another kind of baldness sometimes 
mistaken for ringworm — viz,, a bald, or partially 
bald, patch on the occiput of a young child, which 

* These measurements are taken from Dr. Duliring*swork 
on Diseases of the Skin. 



AND ?BOM ALOPECIA AR1SATA. 63 

has been cansed simply by the head being bored 
in the pillow at night. 

Alopecia Abeata. 

Alopecia areata or circumscripta — formerly 
called porrigo decalvans^ or tinea (?) decalvans — 
is sometimes confomided with tinea tonsurans. 

It is a disease associated with an atrophied con- 
dition of the hair-bulb^ and defective nutrition ; 
and is due to a state of perverted nutrition^ and not 
to any vegetable parasite. 

There is little fear of alopecia areaia being mis- 
taken for tinea tonsurans^ when it extends over a 
considerable portion of the scalp ; but^ what used 
to be called tinea decalvans — viz,, small patches of 
alopecia — may be thought to be ringworm ; and 
sometimes ringworm patches^ that are smooth and 
shining^ are considered to be simply alopecia. 

Dr. Liveing^ in his work on the Diagnosis of Skin 
Diseases^ says: — ^^ Tinea tonsurans occasionally 
produces perfectly smooth^ bald^ shining patches 
of skin^ bearing a close resemblance to alopecia 
areata : — it is the occasional development of these 
temporary^ smooth^ bald patches in common ring- 
worm which has given rise to the erroneous belief 
that there is a parasitic disease called tinea decaU 



64 ALOPECIA AREATA : 

vans, distinct ou the one hand from tinea tonsurans, 
and on the other from alopecia areata; no such 
disease really exists." 

As, until the last few yecrs, some dermatolo- 
gists considered alopecia areata — then often erro- 
neously called tinea decalvans — to be caused by a 
parasite, I think it best to quote the following 
from Dr. Tilbury Fox^s work on Skin Diseases : — 
'^ At the present time there is a 'dead set^ made 
by almost every writer on diseases of the skin 
against the parasitic nature of tinea decalvans, 
and I believe I stand alone in my opinion of its 
parasitic nature : — now I am quite ready to admit 
that this parasitic disease is not common— ^far 
from it, and that the majority of cases of circum- 
scribed baldness observed in the head are not 
parasitic at all. But I cannot but state that I 
have found fungus elements without doubt." 

Dr. Liveing's view offers a probable explanation 
of the facts recorded by Dr. Tilbury Fox, who 
himself admits the rarity of the parasitic affection. 

A remarkable outbreak of so-called tinea decaU 
vans, at Hanwell School, is reported by Dr. 
Hillier,* who also believed in the parasitic and 
contagious nature of this disease. 

* Handbook of Skin Diseases f Dr. Hillier, p. 286. 



ITS NON-PABASITTC NATURE. 65 

But Dr. Dyce Duckworth (in a paper published 
in the St. Bartholomew's Hospital Reports for 
1872, vol. viii.) proves, beyond doubt, the true 
non-parasitic nature of alopecia areata. On page 
162 he refers to the report of the outbreak at the 
Han well School : — " The remarkable series of cases 
reported by the late Dr. Hillier in a large school 
at Hanwell has no doubt inflaenced the opinion of 
the profession upon the subject of the contagious- 
ness of area. Dr. Bristowe is disposed to believe 
that these cases were probably examples of ring- 
worm. The two diseases sometimes co-exist. Mr. 
Hutchinson states that area rarely shows any ten- 
dency to spread by contagion, but he has re- 
corded three cases occurring in one family in 
which he found epiphytic elements. I am unable 
to offer an explanation of these cases, which are 
carefully recorded by this most able observer, and 
I can only express my belief that they may have 
been ' mixed ' cases of area and tinea tonsurans.'^ 

There is no doubt that alopecia areata and tinea 
tonsurans may co- exist at the same time. 

Such mixed cases are not very rare ; and I have 
many times seen patches of baldness caused by the 
'^boracic acid treatment,^' which closely resembled 
alopecia coming on from other causes. I will 
mention one case : — 'In June 1882 I prescribed 



66 MIXED CASES OF 

oleate of mercury for a little girl (aged 11), who 
had chronic ringworm, in patches, all over her 
head. The case was a very severe one, and had 
been at that time under treatment for over a year. 
In October the treatment was changed to thymol; 
but by January 1883 there was no appreciable 
change in the state of the scalp, and the stumps 
were one mass of fish-roe fungus. Boracic acid 
lotion was then ordered. In March many of the 
original ringworm patches were changed into 
places resembling alopecia, and one long bald 
place extended from back to front above the ear. 
Some of the places were like ordinary chronic 
ringworm, and numerous stumps were to be found 
with fungus upon them. In fact the case was a 
complete mixture of ringworm and alopecia. By 
May it was chiefly one of alopecia, and many char- 
acteristic club-shaped stumps were to be seen, es- 
pecially at the circumference of the patches, which 
were enlarging like ordinary alopecia. The stumps, 
under the microscope, were like those described 
on page 70, with deposits of pigment in them. 
Some few diseased stumps were also to be detected 
with the conidia of the tricophyton tonsurans 
upon them. In June the case was one of simple 
alopecia areata, and the patches had much ex- 
tended in circumference. My note-book says: — 



ALOPECIA AND BINGWOBM. 67 

^^Ten bald^ shining^ typical patches^ one large place 
5 by 2i inches^ a fiew clab shaped stamps to be 
seen^ especially at the edges of the patches; no 
fungus to be detected on auy of them/^ 

I doubt if anyone who had not seen this child 
some months previously^ woulJ then have imagined 
that the places had originally been patches of 
ordinary chronic ringworm. 

The treatment was then changed to turpentine ; 
and, in a month, new downy hair was commenc- 
ing to grow over all the places, and the little girl 
was cured. By September the hair was growing 
very freely. 

This is a remarkable case, showing how the 
formation of alopecia — probably by depriving the 
diseased hairs of their fatty materials — cured the 
ringworm patches, by causing the diseased stumps 
to rapidly fall out. In fact this is one way of 
epilating- viz., by producing great dryness of the 
part — and this mode of treatment will be referred 
to again. 

If this case had been first seen in May, it then 
might easily have been mistaken for alopecia, with 
fungus on the stumps. I have seen other cases 
since; and Dr. Liveing mentioned a somewhat 
similar one in the British Medical Journal for 
April 8th, 1882. A boy had seven spots of tinea 

f2 



68 MIXED CASES OF ALOPECfA AREATA. 

tonsurans; and in a fortnight^ while under simple 
treatment, they all became converted into patches 
of alopecia, becoming perfectly smooth, bald, and 
shining. In this case, the bald patches were 
strictly confined to places previously afiected with 
tinea tonsurans. 

Dr. Stowers has also reported some of these 
mix?d cases in The Lancet;* and in most of such 
there are diseased stumps to be detected. 

By these facts not having been recognised in 
past times, two mistakes have often been made. 

First that alopecia areata is a parasitic disease ; 
and secondly, that it is sometimes contagious. 

A paper was also read at the International 
Medical Congress, in 1881, on the cause of alo- 
pecia, by Dr. Liveing — proving its non-parasitic 
nature. It is hardly necessary for me to remark 
that I fully agree with this view, having never 
been able to discover any fungus on the club- 
shaped stumps. 

With regard to the practical question of admit- 
ting a boy or a girl with alopecia into a school, 
there is no fear of the disease spreading, and 
therefore, children with alopecia may be allowed 
to attend school without any risk to others. 

• The Lancet, Feb. 26th, 1881. 



alopecia abeata. 69 

Diagnosis. 

Alopecia Areata is sometimes mistaken for 
tinea tonsurans and treated as such;* and I have 
seen cases where^ at first sights it was difficult to 
decide, as the patches of alopecia were somewhat 
scurfy and contained many long hairs, and numer- 
ous club-shaped stumps. 

In all instances (except in mixed cases or in 
those similar to that described on page 66), alopecia 
areata can be distinguished from tinea tonsurans, 
by a careful examination of the stumps under the 
microscope. In the former affection we see one 
or more, more or less circular, bald spots. The 
places are generally perfectly smooth and shin- 
ing, instead of being scurfy; there is no change 
of colour in the skin, nor is it raised, and no 
ordinary stumps are to be observed; although a 
few club-shaped short hairs, or stumps, are 
usually to be found at the circumference of the 
patch; they even sometimes exist in large num- 
bers. 

* As exception to this statement was taken by one of the 
reviewers of the second edition of this work, I feel bound 
to say that what I have stated is correct. I have had many 
cases (both in adults and children) sent to me dunng the last 
year as ringworm, which were only alopecia ; even two adults 
during the past week. 



70 ALOPECIA AREATA: 

These broken hairs gradually expand towards 
their free extremities, forming club-shaped stumps. 
These are easily extracted entire on traction, in- 
stead of breaking off, as stumps almost always do 
from ringworm patches. The roots are found to 
be small and shrivelled. Under the microscope 
the root is observed to be atrophied ; sometimes a 
little swelled at its upper portion, and then taper- 
ing and reduced in size. The shaft is found to be 
dilated, and darkened in places, forming bulbosi- 
ties which are deeply pigmented in the centre, 
with a large amount of dark granular matter. 
The free end is somewhat club-shaped, more 
opaque and pigmented, and exhibits clusters of 
fibres radiating outwards in a brush-like form 
{Vide Plate IV.). The dilated portions are caused 
by the separation of the fibrillss by the dark 
granular matter; and the brush-like condition of 
the free end is produced by the fracture occurring 
through this part of the hair. No conidia can be 
detected on the stumps. In any doubtful case 
the stumps must be well washed in ether, as 
described page 42. 

At times the hairs in alopecia are half- broken 
or bent over at right angles at one of these pig- 
mented spots, about an eighth of an inch from the 
surface of the scalp. If the hair be examined at 



ITS DIAGNOSIS. 71 

this point it will have the appearance seen in 
Plate IV. 

The above microscopic appearance of club- 
shaped stumps, coming out entire with atrophied 
roots, and no conidia, will easily distinguish them 
from ringworm broken-off hairs, even if many 
exist on a doubtful spot. 

With regard to alopecia, the ordinary appear- 
ance of the patches has already been described. 
They are commonly seen on the head, but may 
occur on the eyebrows,^ or hairy parts of the face. 
As the disease spreads, the hairs around easily 
come out, and, by the patches uniting, large 
irregular places of area are formed. The adjacent 
long hairs can usually be extracted with ease, but 
sometimes they are quite firm. When the patches 
are getting better, new downy hair will be seen 
growing upon them. Sometimes a place will be 
found to be spreading at one end, with numerous 
stumps, while the fine new downy hair is appearing 
at the other. 

Alopecia may occur at any age, and of every 
degree of severity, from one place to a complete 
loss of every hair on the body. It often recurs, 
and has a disposition to appear in different mem- 
bers of the same family. 



72 ALOPECIA AREATA. 

The causes of this disease are not understood. 
Its origin is to be found in some functional nerve 
disturbance^ causing impaired nutrition. This 
disease may last almost any time^ and no definite 
opinion can be given as to when it will get well. 
Months or years may elapse before the Iiair grows 
again. In some rare cases it is never restored. 
The younger the patient the more favourable the 
prognosis. 

For the treatment of alopecia areata, see Chap- 
ter XI. 



TINEA CIBCINATA. 73 



CHAPTER V. 

Ringworm of the Body^ the Beabd^ and the 
Nails^ and its Treatment. 

Tinea Circinata, or Ringworm of the Body. 

Tinea circinata, formerly called herpes cirdn- 
atuSy is essentially the same disease as tinea ton- 
surans; and though other names are given to 
varieties^ especially to ringworm in hot climates^, 
yet this term will include all forms. 

Etiology. — The usual places to find patches of 
body ringworm are the face, neck, chest, and 
arms of children who are suflfering from ringworm 
of the scalp ; or who are mixing or playing with 
other children who have untreated tinea ton- 
surans. At times it is prevalent in Public Institu- 
tions, and then it generally co-exists with tinea 
tonsurans. 

Sometimes clothes, comforters, etc., get in- 
fected, and are the continued source of fresh mis- 
chief. Again, ringworm is often spread from 
place to place on the body, by the absence of 
proper ablutionary measures. 



74 EINGWORM OP THE BODY: 

It is highly contagioas; and may even be 
taken from the lower animals^ such as cows, 
horses^ dogs, cats, and rabbits. Under these cir- 
cumstances the disease usually exhibits a severer 
type than when contracted from man. 

Adults, though they may be constantly exposed 
to the action of the fungus — as nurses — rarely 
take the complaint. As Dr. T. Fox remarks : — 
'' Something more them mere contact is needed in 
the adult to insure contagion.'* 

Diagnosis. — The appearance of body ringworm 
is very different from disease of the scalp, as no 
long hairs exist. If patches of tinea circinata be 
observed at an early stage, they appear as small 
reddish, raised, circular spots — each about the size 
of a split-pea, or less — often herpetic in character. 
These generally quickly enlarge at their circum- 
ferences—where the redness and minute vesicula- 
tion is most marked — while the centres become 
flattened and somewhat natural again. The mar- 
gins of these annular patches are slightly elevated, 
and sharply defined against the healthy skin, form- 
ing rings. The vesicles are only pin-point or pin- 
head in size, are extremely evanescent, and do 
not leave a crust, but only simple desquamation. 
Often vesicles are not seen, but only red, raised, 
scaly, erythematous patches. 



ITS DIAGNOSIS. /5 

The places^ when first noticed^ are generally 
abont the size of a sixpence to a five-shilling piece, 
slightly raised, and covered with a fine branny or 
forforaceous desquamation ; and, as they enlarge 
by centrifugal growth, the skin in the centre be- 
comes nearly normal again, or has a whitened, 
scurvy and shrivelled appearance. The minute 
papules and vesicles exist about the periphery; 
and the rings (whence the name ringworm) thus 
formed, may coalesce aud cause iiTegular patches 
or semicircles and segments of circles. The places 
may be as large as the palm of the hand, or 
larger by coalescence. 

At times the disease starts afresh within the 
part already swept over, and the result is a ring 
within a ring. Very often when the patch has 
reached a considerable size, the disease dies out at 
portions of the circumference, and segments — more 
or less broken — advance over other portions of the 
skin. As a rule only two or three places are pre- 
sent, but sometimes a large number will be seen, 
especially about the chest. When situated on 
the face or neck, it may extend on to the scalp ; 
or in men it may spread into the beard causing 
parasitic sycosis. 

Itching is generally a marked symptom in body 
ringworm. 



76 BINGWOBM OF THE BODT : 

The disease is saperficial, and shows no disposi- 
tion to symmetry^ except perhaps through con- 
tagion in certain regions, as on the inner sides of 
the thighs. Body ringworm is generally a trivial 
affection in England^ but obstinate cases some- 
times occur, especially about the genito-crural 
region in adults ; the disease may also be recur- 
rent. 

Its course is variable, depending upon the part 
attacked, the general condition of the patient, 
and the climate. 

Pathology. — The fungus after being implanted 
on the skin, under suitable conditions of soil, heat, 
and moisture, permeates the epidermis in all 
directions, causing hyperssmia, inflammation, vesi- 
culation, and desquamation. 

Under the microscope the epidermic scales are 
found to have mycelium threads and conidia 
ramifying between them. 



Microscopical Examination. 

To obtain scales for examination, the inner part 
of the outer ring, just where it is commencing to 
desquamate, should be scraped with a blunt knife: 
and the epidermic scales thus obtained should be 
placed in a drop of liquor potass89 on a glass slide, 



MICHOSCOPICAL EXAMINATION. 77 

and the thin cover-glass applied^ and the mass well 
jBattened out by pressure upon it. The fungus 
may not be found if the cells are only taken from 
the outer portion of the ring which is not de- 
squamating, or from the central portion, when 
nearly healed. A power of 450 to 800 diameters 
should be used, and the threads will be observed 
best after the specimen has stood an hour, as at 
first they have a very faint outline. 

The mycelium is seen as long — sometimes very 
long— slender, pale-greyish, sharply contoured 
threads^ like ribands, jointed at irregular inter- 
vals, and branched here and there in all directions, 
forming a network between the epidermic scales. 
They vary in size from '0018 mm. to '0026 mm. 
(Vidp Plate V.). The outline of the threads is 
always clearly defined with parallel lines, and they 
contain a few conidia here and there, and granular 
matter. The conidia vary in size from *0021 mm. 
to '0035 mm., and are seen singly or in chains, 
and may be isolated or connected with the 
mycelium. It is important not to mistake shreds 
of wool or cotton for mycelium, and especially not 
to confound the margins of the epidermic scales 
where they overlap one another, and thus often 
give the appearance of mycelium threads. The 
diagnosis is easy if the fine adjustment be turned 



78 UNOOMMOH lORXS OF BODY BINQWORM. 

a little^ when the ondine of the cells will appear. 
Great care must also be taken not to mistake fat 
globules, pns, or otiier cells for conidia. If in 
doabt, the preparation should be well washed with 
ether. 

The fungus is usually easily discovered in the 
early stage of body ringworm ; but later on it 
is not so easy of demonstration. 

Incubation pbbiod. — Vide page 45. 



Uncommon Forms op Body Eingwobm. 

Large patches are sometimes seen on the back 
of the hand^ or front part of the wrist. They have 
more the appearance of eczema, but have a well- 
defined edge with papules, and often slight crusts. 
It is difficult to find any fungus in these cases, 
and yet they rapidly get well under the use of 
parasiticides. 

Under the combined influence of heat and mois- 
ture — especially in hot climates — ringworm of the 
body may be severe and extensive. The patches 
are very large, and may spread over various 
regions, but in adults the inner surface of the 
thighs, groins, and the parts between the nates 
are usually involved, and may be very rebellious 



INDIAN AND CHINESE EINQWOBM^ ETC. 79 

to treatment : this variety is called eczema mar» 
ginatum. 

In other cases there may be places scattered 
over the thighs^ axillsB^ front of the chesty or neck 
and face. These severer forms are much more 
common in hot climates. 



Indian, Burmese, Chinese Eingwoem, etc* 

'' In various parts of the East many local de- 
signations are given to ringworm of the surface 
of the body. There, in fact, would appear to exist 
in different places peculiar diseases, apparently 
different, but in reality one and the same in 
nature. Chinese, Burmese, and Tokelau ring- 
worms are examples in question. It is pretty 
certain that these affections are nothing more or 
less than ordinary ringworm of the body, such as 
we have in Europe, determined in their occur- 
rence to certain parts of the body by peculiar 
circumstances, and assuming characters some- 
what different from those observed in the disease 
as it exists in colder climates, in consequence of 

* The accompanying account is quoted from Dr. Tilbury 
Fox^s work " On Skin Diseaies,** to which the reader is 
referred for further information on the rarer forms of tinea 
circinata. 



80 ECZEMA MARGINATUM. 

the greater laxuriance of the parasite^ consequent 
upon the presence in the one case of a greater 
amount of heat and moisture^ which are favour- 
able to the development and spread of growth of 
fungi/' 

These affections then are no new diseases^ but 
can be included under the term tinea circinata. 



Eczema Marginatum. 

Eczema marginatum, is the name given to a 
variety of ringworm, sometimes seen in cavalry 
men and others^ and attacking the inner sides of 
the thighs, and the parts between the nates and 
the genitals. 

It commences as a red^ raised patch of papules 
and vesicles, which itches very much, and excites 
much scratching; it increases by centrifugal growth 
and the circumference has a well marked and de- 
fined border, with papules, vesicles, and crusts. 
As it spreads under friction, warmth, and moisture, 
it heals in the centre, leaving a dark-red scaly con- 
dition of skin ; and later on, there is marked pig- 
mentation. The scratching aggravates the disease 
and gives it a markedly eczematous appearance : 
and if it has existed some time, the parts get 
thickened by constant rubbing, as the complaint is 



BJNGWOBM TRANSMITTED VBOM ANIMALS. 81 

attended with much irritation. It differs from 
ordinary ringworm by the eczematous character of 
the lesions^ and the congestion and pigmentation 
of the skin. 

It is generally accompanied at first with a 
luzuriant growth of mycelium, and though the 
fungus may then be easily detected — if a few of 
the scales on the outer edge be scraped off and 
examined — ^yet, if dermatitis has been set up, and 
the disease has passed into the chronic form, it 
may be absent, and the place then partakes more 
of the character of eczema. This variety is a very 
difficult one to cure^ and often lasts for years. 



TiNBA GiBOINATA TRANSMITTED FROM AnIMALS. 

It is a well-known fact that ringworm may be 
transmitted from the horse, calf, cow^ dog, cat, and 
rabbit, &c., to man. The disease is an exaggerated 
form of tinea, and usually exists about the arms or 
hands of those engaged in attending on the dis- 
eased animals. Dr. T. Fox has reported some 
cases, and I quote his words : — 

'^ The inflammatory aspect of the patches was 
more severe, the infiltration more decided, the 
extent of the eruption greater than usual, and the 



82 BODT sinowobm: its diagnosis 

herpetic character^ when the earlier stages were 
observed^ not at all abortive, but much more dis- 
tinct than usual. Moreover, the fungus, luxuriat- 
ing amid the textures of the skin, set up so much 
irritation as to produce pustulation in place of the 
ordinary herpetic vesiculation in certain of the 
patches. In fact, the features of tinea circinata 
were not only peculiarly well marked, but exag- 
gerated.^' 

This variety of the disease has the appearance 
of a well-defined eczema in circular patches ; and 
pustules often exist. 



Diagnosis of Bingwobm of thb Body. 

BiNGWOBM of the body may be mistaken for 
squamous eczema, seborrhoea, etc., and many affec- 
tions have at times been confounded with tinea 
circinata. The latter can usually be distinguished 
by its history — commencing from a small red spot, 
which is generally attended with itching — ^by its 
rapidly assuming the annular form and keeping to 
it ; by its abrupt and sharply defined edge against 
the healthy skin ; by the papules and slight vesi- 
cles sometimes seen at its circumference, which 
is slightly raised above the surface of the skin ; by 



FROM SBBOBBHGBA^ JlND FSOBIASIS. 83 

its slight desquamation ; and by its becoming pale 
and somewhat normal again in its centre, while 
spreading at its periphery. Dry patches of squa- 
mous eczema or seborrhoea are often symmetrical, 
but spots of ringworm are hardly ever so, except 
as the result of direct contact, as on the thighs, 
nates, or axillas. But, as the tricophyton is the 
undoubted cause of this affection, it is advisable 
to employ microscopic aid in all cases of doubt. 

Sbbobehcba, or pityriasis — especially of the 
face and back — sometimes very closely simulates 
ringworm, and it may even take on an annular 
form and desquamate like tinea circinata. 

But the latter can generally be diagnosed by 
the characters above mentioned, by its inflamma- 
tory nature, and by the absence of enlarged 
follicles, and of a greasy surface ; while a patch of 
seborrhoea is rarely circular, and has the same 
appearance all over, and does not become normal 
again in its centre. 

Psoriasis. — Some patches of psoriasis — ^if of 
annular form — ^much resemble those of tinea cir- 
cinata, but they can be diagnosed by the presence 
of other small spots about the body — espedaUy 
about the elbows and knees — by the characters 
named, and by the history of the case and the 
microscope. As a rule, the uniform redness, and 

g2 



84 BODT bikgwobm: its diagnosis 

the accamulation of scales^ easily distingaisU 
patches of psoriasis from discs of ringworm. 

EczBMA. — We often see round, red, scaly places 
which are only eczema ; and sometimes, patches 
of ringworm on the back of the hand and wrist, 
nates, etc., closely simulate eczema, but they can 
usually be recognised by the characters given. 
Eczema marginatum can be diagnosed by the 
symptoms already mentioned, by its site, and by 
microscopic aid. The itching in this disease is 
always severe, and its course is very chronic, often 
remaining in the same situation fpr years. The 
marginate character of the patches points to a 
parasitic cause. 

Ebtthema cibcinatum, annulabb and maboina- 
TUM. — All these varieties of erythema may be mis- 
taken for ringworm. In the former affections we 
find one or more circular patches of erythema, 
fading in their centres while they extend at their 
peripheries with well defined edges, which are 
raised and thickened. Erythematous patches are 
often symmetrical; and I have seen the body 
almost covered with them, and some have been 
undistinguishable, by the naked eye, from ring- 
worm ; so that even experienced observers were 
mistaken. 

In erythema iris a series of concentric rings 
exists, which will usually distinguish it. 



FBOM HERPES IBTS^ AND OIBCINATUS. 85 

The characters given above will generally en- 
able a diagnosis to be made ; but^ in doubtfal 
cases^ the microscope should always be employed^ 
when the presence or absence of the fungus will 
settle the question. 

Hebpes ibis. — ^This must also be distinguished 
from ringworm. In this affection we find a num- 
ber of vesico-papules^ or vesicles arranged so as to 
form a complete ring. There may be two or more 
of these rings one within the other^ like erythema 
iris. Herpes iris first appears as a few papules 
round a central pointy these soon become vesicles^ 
and spread in the form of a circle. When one 
ring is formed^ another appears outside it, and 
sometimes many follow. By remembering these 
characters the diagnosis is generally easy, without 
microscopic aid. 

Hebpes oiboinatus. — ^Much confusion has arisen 
from this term having been formerly applied to 
ringworm of the body, because of the presence of 
quasi- vesicles which so often form at the circumfer- 
ence of patches of tinea circinata. At times 
patches of ringworm may closely resemble those 
of herpes, but in all cases the diagnosis should be 
made, first by the history — commencing as a red, 
rough, scurfy spot, then gradually enlarging at 
the periphery, while the central portion becomes 



86 BODT BINOWOBM : ITS DIAGNOSIS 

pale and desqaamates — and secondly^ by the 
microscope. Again herpes runs a definite course^ 
while ringworm may be indefinitely prolonged 
unless properly treated. The term herpes circin- 
tas should be avoided altogether^ and certainly not 
appUed to ringworm of the body. 

Lichen cibcikatus^ ob oibcumsobiftus^ is an affec- 
tion that may bemistakenforringworm ; and is usu- 
ally situated on the back and chesty or between the 
shoulders. It consists of groups of papules^ which 
have a tendency to spread at their circumferences 
forming rings. These rings have well defined 
margins^ while the skin in their centres becomes 
somewhat normal again^ or of a yellow color. 
Thus yellowish spots are seen with red borders. 

PiTYBiASis MACULATA BT ciBCiNATA is a term em- 
ployed to designate a peculiar disease^ occupying 
chiefly the trunks and characterised by the devel- 
opment of discrete or conflaent slightly raised 
macular or maculo-papular patches^ varying in 
size : but it may be doubted whether this is an 
affection distinct from circinate lichen. The 
places are rounded^ sharply circumscribed^ with 
a ring- like border; and the surface is reddish^ 
dry^ and more or less scaly. The skin is but 
little thickened ; and the patches^ like those of 
tinea^ tend to heal in their centres^ while they 
spread at their peripheries. 



FROM P1TTEIA8I8 VBR8IC0L0B. 87 

Both these diseases sometimes closely simulate 
eruptions of tinea circinata^ and have the general 
appearance and course of vegetable parasitic dis- 
eases^ but there are no fungus-elements to be 
found. 

Pityriasis versicolor. — ^This affection (which is 
very rarely seen in children) is not very likely to 
be confounded with ringworm^ though the scales 
exhibit well marked conidia and mycelium threads 
when examined under the microscope. In pity- 
riasis we see spots^ or large patches of disease 
by coalescence^ occupying chiefly the trunk — on 
parts not exposed to the air^ especially the skin 
over the sternum and between the shoulder blades — 
of a light yellow, or yellowish-brown color ; and 
scarcely, if at all, raised above the level of the 
skin. The whole surface of the patch is of the 
same uniform tint, and there are no distinct scales, 
but only fine branny or furfuraceous desquama- 
tion. The margins of the patches are well defined, 
and not more congested than the rest of the sur- 
face ; and they are not raised, as in ringworm, 
but are flat. Again, it has no tendency — like 
ringworm— to heal in the centre. 

On microscopical examination of the scales we 
find the conidia are somewhat larger than those 
of the trycophyton, and irregularly circular in 



88 BODT BIN6W0BM: ITS DIAGNOSIS. 

shape: and what distinguishes them from the 
spores of other vegetable parasites is their tend- 
ancy to aggregate and crowd together into groups 
and heaps. These heaps of conidia are placed at 
regular intervals from one another, and are joined 
by the network of mycelium. This peculiar 
grouping of the fungus is quite characteristic. 

Favus is not likely to be confounded with body 
ringworm if the characteristic yellow crusts be 
present, but if they have all fallen off a mistake 
can easily be made. The lesion of favus is less 
distinctly circinate than that of ringworm, but 
the microscope will decide the question, even if 
only a small portion of a crust can be found, as it 
will be seen to consist almost entirely of fungus. 
{Vide p. 61). 

Syphilitic Eruptions may resemble tinea — only 
the erythematous or the serpiginous varieties — 
but they are not attended with itching. The 
history of the case, and other symptoms, will 
generally help us to form a diagnosis. 

But in these, as in all doubtful, scaly, circular 
spots, a careful examination of the scurf under the 
microscope will show the mycelium if present, and 
settle the diagnosis. But, if the disease is of long 
standing, and is complicated with eczema as in 
eczema marginatum, the fungus is often very dif- 
ficult to detect. 



BODY RINGWORM : ITS TREATMENT. 89 



The Treatment of Body Eingworm. 

Ordinary recent varieties. — Body ringworm 
in children, and recent patches, are generally 
quickly cured by any parasiticide. The fungus is 
near at hand and can easily be reached by reme- 
dies, even ink at times being sufficient. 

One of the best plans is to paint the patches, 
and for a quarter of an inch outside them, a few 
times either with acetic acid (ac. acet. fort.) two 
parts, mixed with iodine liniment one part ; with 
acetic acid : with iodine liniment and tincture 
of iodine, equal parts ; or with a modified Coster^s 
paste : — 

^ lodinii, 3ij. 

01. Junip. Pyrolig., ad Jj. M.* 
(Huile de cadej, 

— at intervals of one or two days, if they are situ- 
ated on the neck or body ; but, if on the face, 
these remedies generally cause too much irritation. 

• Co8ter*8 paste is made with colorless oil of tar. I prefer 
the oil of cade for ringworm of the hody, as it forms a stiffer 
paste, especially after being made and exposed for a time to 
the air. This thicker preparation is not so apt to run, as the 
ordinary Coster's paste. 



90 fiODT bingwobm: its tbeathent. 

In such cases^ and with yoang children^ I prefer a 
solation of boracic acid^ or of sulphate of zinc, 
(one drachm to the ounce) ; boro-glyceride; or car- 
bolic acid mixed with four to seven parts of gly- 
cerine jelly (glycerinum amyli). Another excellent 
plan is to frequently paint the places with freshly 
made sulphurous acid^ diluted with glycerine. 

Bichloride of mercury (two or three grains to 
the ounce of lard^ or in a lotion with spirit); 
dilute citrine ointment^ (about one part to five or 
iseven of lard) ; oleate of mercury^ and oleate 
of copper ointment^ Dr. Shoemaker^s (one drachm 
to the ounce); are also useful remedies. 

In choosing a parasiticide the medical man must 
be guided by the age of the patient^ the extent 
and the seat of the disease^ the state of the skin^ 
and whether inflamed or complicated with eczema. 
Very simple remedies are generally suflBicient with 
young children, even white precipitate ointment. 

The application of Goa powder or chrysophanic 
acid ointment to the face or neck is not to be re- 
commended as it produces much discoloration, and 
often severe irritation and swelling of the eyelids ; 
and I have more than once seen impetiginous 
eczema of the face caused by its use. But it is a 
valuable parasiticide, and is highly esteemed 
in Eastern countries, especially for the more in- 



BODY BINOWOBH : ITS TBBATMBNT. 9 1 

veterate varieties of body ringworm. The Bombay 
Groa powder* can be safely ^used for patches of 
tinea^ which are not sitaated on the face^ and 
there is no doubt that it is a very efficient remedy. 
If Goa powder is employed, the proper way 
to nse it is to well wash the place with soap and 
hot water, and then, after rinsing, but while the 
patches are still moist, to rub a little of the pow- 
der into the ringworm with the tip of the finger, 
or a small mop.t This can be done for a few 
minutes, and repeated the following day. Two or' 
three applications are usually sufficient to cure the 
disease. Care must be taken not to leave any ex- 
cess of the powder, so that it will fall oflF the skin 
when dry. The Bombay Goa powder is to be pre- 
ferred to ordinary Goa powder, or an ointment 
made with chrysophanic acid,{ which causes much 
more staining and irritation, and often impeti- 
ginous eczema. If the acid is used, five grains to 
the ounce of ointment is quite strong enough. 

• " Chrysarobine." Messrs. Kemp and Co., Bombay. 

f The mop can be made by tying a small bit of wool, 
covered with a piece of linen, on to the end of a paint-brush 
holder. 

X The powder that is extracted from Goa powder, and 
sold as chrysophanic acid, is not chrysophanic acid but 
chrysarobin* 



92 TBEATMENT OF ECZEMA MARGINATUM. 

A better way of nsing chrysarobin is to dissolve 
it in chloroform — as mentioned further on^ nnder 
the treatment of recent ringworm of the head. 
Seven grains to the ounce of chloroform forms a 
lotion which may be used to all patches of body 
ringworm^ except those situated on the face. 
When applied it generally causes some pain^ and 
the yellow powder^ left after the evaporation of the 
chloroform adheres to the skin. This is better 
than greasy ointments^ especially for large patches^ 
and for ringworm in hot cUmates.'' 

In treating body ringworm we should avoid 
causing too much irritation ; and if the places are 
eczematous and irritated^ a mild tar ointment will 
be found a good application^ or an ointment with 
some oil of cade in it. 



The Treatment of Eczema Marginatum. 

The usual precautions must be adopted^ and one 
of the following remedies can be used. 

Sulphurous acid is one of the best applications. 
It is of importance that this preparation should 
he freshly made, as the acid gets weaker by keep- 

* See, also a letter in the Brilith Medical Journal £or Jan. 
24th, 1885. 



TREATMENT OF ECZEMA MARGINATUM. 93 

ing^ and also becomes partly oxidised into sul- 
pharic acid. Sulphurous acid (6.P.) should be 
well sponged on the parts for fifteen minutes at a 
time many times a day. Sulphur is also a very 
useful application^ and may be used in the form of 
sulphur ointment^ with some oil of cade (two 
drachms to the ounce). 

Dr. T. Fox advises a solution of hyposulphite 
of soda (one drachm to the ounce) to be applied 
on linen rags under oil-silk^ for at least an hour at 
a time, night and morning, after the parts have 
been thoroughly washed with soap and water. 

Chrysophanic acid ointment (five grains to the 
ounce of lard) ; or, what is much better, the 
solution in chloroform and the Bombay Goa 
powder, applied as before described, are valuable 
remedies. 

Bichloride of mercury (two grains to the ounce) 
can be used to cure this variety of the disease ; 
also a saturated solution of boracic acid in spirits 
of wine, boro-glyceride, and oleate of copper* 
ointment. 

• Dr. Shoemaker's, Fide Chapter VIII. 



94 PBKYBNTIVE AND OSNIBAL TBBATMINT. 



Pksybntivs Tbiathekt. 

It is advisable to have all the body-linen and 
flannels boiled ; and a bath should be given^ and 
the whole body well washed with carbolic add 
soap (ten per cent.) ; the bath should be repeated 
every two or three days^ if the disease is at all 
extensive or recurrent. 

One important practical paint to remember, is to 
thoroughly examine the head of every child who has 
a spot of body ringworm^ as the slighter affection 
is very often only secondary to disease of the 
scalp. 

General Tbeatment is not needed, unless in 
some rare cases where the disease continually 
crops up^ and appears partly due to debility. 
Then arsenic^ iron^ and cod-liver oil may be given. 

Isolation. — Children with body ringworm should 
be isolated for a time, but under efficient treat- 
ment^ the fungus is soon destroyed, and the 
disease cured. Treatment should be continued 
till the patch is thought to be well, then vaseline 
can be applied for a few days to see whether there 
is any recurrence of the disease. 



WHEN CUBED? AND TINEA 8TC0SIS. 95 



Whef isTineaCircinatatobe Considered Cubed? 

A patient with ringworm of the body, must 
not be certified as well^ until the skin is almost 
normal again at the circumference of the patch, 
and the margin is quite free from all papules, and 
desquamation. Nor should the place be at all 
raised above the surface of the surrounding skin. 
If in doubt, the skin just inside the margin of the 
patch should be scraped, and the epidermic scales 
examined, as before described, under the micro- 
scope. 

Parasitic Sycosis — Tinea Sycosis. 

There are two distinct varieties of sycosis, one 
parasitic, the other not. In England, the ring- 
worm fungos at times attacks the hair of the 
beard, giving rise to the parasitic variety of 
sycosis, but it is a common disease in France. 

In the first stage, it commences like an ordinary 
patch of tinea circinata, and the place spreads 
with papules and an elevated margin, accompanied 
with mnch itching and burning ; while the centre 
remains red and scurfy. Other places soon appear 



96 TINEA srooBis: 

and the disease may spread over the beard. At 
first the hairs do not fall out^ but sooner or later 
they get involved and break off^ leaving ragged 
stumps. Often the disease spreads beyond the 
beard^ forming patches of ordinary ringworm on 
the skin of the neck ; or it may commence on the 
neck^ and involve the beard secondarily. In this 
affection the hairs break off^ as in ringworm of the 
scalp^ and, under the microscope, are seen to be 
swarming with the fungus, as described under 
tinea tonsurans. 

The usual cause of this affection is the barber^s 
razor — hence the name "barber's itch*' — and 
therefore it rarely affects those who wear a long 
beard, or those who shave themselves. 

After a time swelling and induration come on,^ 
and the second stage of the complaint is reached. 
The hair- follicles get deeply involved, and shaving 
becomes very painful. After a time the skin gets 
nodular, and the follicles generally inflame and 
become indurated, when the disease very much 
resembles true sycosis. The deeper tissues may 
become involved ; and firm, raised masses of in- 
duration are formed, with a congested colour, and 
tubercles and pustules. 

The hairs get dull and brittle, and the broken 
stumps can often be extracted entire, because 



ITS DIAGNOSIS. 97 

they are loosened by inflammation and pustnla- 
tion; the majority, however, will break off. Often 
the stumps are so rotten from the action of the 
fangus, that only black dots are to be seen, and 
it is di£Scult to remove even a small portion of 
hair for microscopical examination. 

The tubercles are very characteristic, and may 
form large uneven masses of induration, with but 
slight pustulation. At other times the pustula- 
tion is excessive, and crusts form like impeti- 
ginous eczema, quite masking the disease. 

The places usually attacked are the submaxil- 
lary regions and the chin. The upper lip and the 
upper portions of the face are rarely infected. If 
left untreated, it generally spreads all over the 
chin, from one side to the other ; if neglected, 
this affection may last for years, and, if the fungus 
be not thoroughly eradicated, it will probably re- 
lapse. 

Only a very few adults who are exposed to the 
action of the ringworm fungus take parasitic 
sycosis, as some unknown condition of soil is re- 
quisite for its development; and as before noticed, 
a direct inoculation by the " public razor " of the 
barber, is the usual cause. 

Diagnosis. — In its first stage it is easily recog- 
nised by the characters already given for body 



98 TINEA STCOSIS: ITS DIAGNOSIS. 

ringworm^ and when ,the stumps have formed 
there ought not to be the least difficulty about the 
diagnosis; but when the second stage has been 
reached it may be confounded with non-parasitic 
sycosis^ and with acne. Very often the ringworm 
extends on to the neck or face^ beyond the limits 
of the beard-— especially in the first stage — and 
then the usual characters of tinea circinata are 
seen. Parasitic sycosis generally spreads all over 
the beard^ while the non-parasitic variety is often 
restricted to a certain portion^ and as a rule^ ex- 
hibits more crusting. The upper lip is rarely in- 
vaded in parasitic sycosis^ while it is often involved 
in the non-parasitic variety. The hairs in the 
parasitic form are swollen and brittle^ and broken 
oS, forming stumps or black dots. They are 
sometimes loose^ and may be extracted without 
pain^ while they are firmly fixed in the non-para- 
sitic variety. In acne, other spots are seen on 
parts of the face free from hair. But the micros- 
copical examination of the stumps will always 
decide the question. 

Sycosis may remain as an independent malady 
after all the fungus has been destroyed. 



TINEA STCX)SIS: ITS TBEATMSNT. 99 



Tbiatment of Parasitic Stcosis. 

This troublesome disease often takes many 
months to cure^ for the fungus is deeply situated 
in the hair-follicles^ as in ringworm of the head. 
The best treatment is to epilate freely^ and to 
employ some parasiticide. 

The boracic acid lotion (described in Chapter 
VII.) is a very good remedy ; and^ if the case be at 
all recent^ it should be tried first. In fact I have 
seen so many rapid cures with this lotion^ both of 
ringworm of the head and of the beard^ that I 
generaUy give it a fair trial before prescribing any- 
thing else. I have found the constant application 
of oleate of mercury (one in ten) a most effectual 
remedy^ combined with frequent and careful epi- 
lation of all diseased hairs and stumps. The 
oleate ointment should be freely rubbed and 
dabbed into the hair-follicles^ night and morning, 
with a small sponge mop. When the fungus is 
thoroughly destroyed, by the oleate soaking to 
the bottom of the follicles, new healthy hairs will 
appear, and the scabs, etc., can then be removed 
by simple treatment. 

If the case be a severe one, and many crusts 
exist, they must first be removed by warm oil 

H 2 



100 BINaWOBM OF THE NAILS: 

and washing. It is well to keep the hair closely 
cut^ bnt yet long enough to allow the broken 
hairs^ or stumps, to be seen and removed. 

Oleate of copper ointment (one in eight), can 
also be employed, and the bright green colour 
avoided by thoroughly rubbing it into the hair-fol- 
licles, and removing any excess that may be left 
on the surface of the skin.* 

Bichloride of mercury (two grains to the ounce), 
is a good lotion, and so is sulphurous acid. Dilute 
citrine ointment is also used to cure this disease, 
or an ointment with sulphur, ammoniated mer* 
cury, and the red oxide (three grains to the 
ounce). 



BiNGwoBM OF THE Nails: Tikea Trichophytina 
Unguium : Ontchomtkosis. 

Very rarely some of the finger-nails become in- 
fected with the ringworm fungus. It may pos- 
sibly occur in those who are attending ringworm 
cases. The nails get dry, opaque, thickened, 
furrowed, fissured, and brittle, especially along 
their free borders. This disease can only be dia- 

* See Chapter VIII. for remarks on Dr. Shoemaker's 
oleates of mercury and copper. 



ITS TEEATMENT. 101 

gnosed by finding the fungas-elements. It pursues 
a chronic course, and it is very diflScult and tedious 
to cure. 

Teeatment. — One of the best plans is to scrape 
the nails as much as possible, and to apply strong 
acetic acid about every other day. The nails 
should also be kept soaked in sulphurous acid, or 
in a solution of hyposulphite of soda (two drachms 
to the ounce). 



102 sidBT sorgwosK: its TBiAnocNT. 



CHAPTEB VI. 

ThS TbIATIRHT of BlCINT BlNOWOBM OV THB HsAD. 

nmoBucTosT sdi abks. 

The qnesidon of the easy curability of any given 
case of ringworm of the head — except in very 
young children — ^usually depends upon the length 
of time the disease has existed^ before it comes 
nnder efficient treatment^ and the special condi- 
tion of the soil. 

Nothing is easier to cure than a patch of ring- 
worm situated on the body^ bnt it is a veiy 
different matter when it exists on the hairy scalp. 
Then the treatment is^ as a role^ most disappoint- 
ing. Quick cures are very rare^ and sure results 
are only to be obtained by thorough and long- 
continued employment of active remedies. 

It is necessary to keep in mind the important 
facts^ that the fungus is the essential cause of the 
mischief; that it soon extends to the bottom of 
the hair-follicles; that its destruction is indis- 



SELECTION OF A TREATMENT. 103 

pensable in order to cure the disease; that the 
great difficulty in curing ringworm is not to find 
parasiticides^ but to get them to penetrate deeply 
into the hair-follicles^ and thus come into contact 
with the fungus. 

Bemedies act in two ways, first, by destroying 
the fungus — ^parasiticides — such as boracic acid, 
sulphurous acid, and the oleates of copper and 
mercury ; others act by setting up inflammation, 
and even exudation about the follicles, and by this 
means cure the disease — as croton oil ; but by far 
the majority combine both these properties, as 
acetic and carbolic acids, Goa powder, chrysaro- 
bin, nitrate of mercury, etc. 

It is very unwise to make a large sore place on 
the scalp, especially in recent ringworm, as the 
pustular variety may thus be set up ; and strong 
preparations should never be used to young 
children. 



Selection of a Tbeatment. 

There are hundreds of different ways of treating 
ringworm of the head, and many ^^ never- failing " 
nostrums, 'which are warranted to cure the dis- 
ease in a few days or weeks. 



104 BSOBNT bingwobm: its tbxatmsnt. 

The reason why so many things are said to core 
ringworm, is dae to two caoses ; firstly, many cases 
are only ringworm of the body ; secondly, number- 
less children are said to be well, when they still 
have ringworm in the most chronic form, and thus 
remedies are said to cnre cases that have never 
been influenced for good by them. I have so 
ofben drawn attention to this fact that this may 
appear mere repetition, but considering the number 
of children constantly sent to me already certified 
as " cured,'' who have ringworm in a contagious 
form, it would appear that all that has been written 
on this subject has made but little impression on 
some medical men. 

The plain truth is that there is not a single 
plan (except the use of strong caustics which will 
form scars) which can be relied on with absolute 
certainty to cure ringworm of the head. The 
rapidity with which different cases, of apparently 
equal severity, yield to similar treatment varies 
greatly. Some go on unchecked for months, or 
even years, and may even spread under good 
treatment — while others rapidly get well. A 
remedy which cures one child may utterly fail 
with the next. It would be useless to mention 
all the various ways that have been suggested for 
the eradication of this troublesome complaint; 



TSEATMENT WHEN THE CASE IS FIRST SEEN. 105 

and in what follows^ I shall speak first of those 
remedies which experience has shown to be most 
effectual in the majority of cases^ and then men- 
tion others which may be tried^ should the first 
fail^ or for any reason be thought unsuitable. 



Treatment when the Case is First Seen. 

When a case of ringworm first comes under the 
doctor's care for treatment^ the most important 
point to determine (afber deciding how long the 
disease has existed) is ths extent of surface involved^ 

The whole head therefore should be most care- 
fully examined^ and directly a patch of the disease 
is discovered^ it should be marked out^ by cutting 
the hair from it^ and for a quarter to half an inch 
round it. 

Bemoval 07 THE HAIR. — Thou^ if the patches 
are at all numerous^ or cover any large extent of 
the scalp^ U is absolutely necessary (in my opinion) 
to remove roost of the hair from the head. Shaving 
the scalp is preferred by some^ but it is not at all 
essential^ and very close cutting is equally efficient. 
The objection to shavings is that it is often badly 
done^ and then the little cuts and cracks get irri- 
tated by the remedies. Therefore I prefer to havo 



106 BVCBNT bikgwobm: its tbsatxbnt. 

the hair very closely cat with scissors* all over the 
top of the head, leaving a small fringe all ronnd, 
or certainly at the back and front, for appearance 
sake. The fringe should always be left, if the 
disease does not extend to the forehead or the 
neck, as the look of the child is so mtich improved 
by it when a cap is worn. It can do no harm, as 
the parasiticides employed can easily be rubbed 
into the roots of the hairs that are left. 

In cases where there are only three or four 
small places, it is sufficient to cut the hair off the 
patches, and for about half an inch round them ; 
but the rest of the hair — ^if a boy — should be cut 
short, about half an inch to one inch long. 

It is always a serious matter when the hair has 
to be almost entirely cut off from the head of a 
girl, but still it should be done if the disease is at 
all extensive, or else it is almost certain to spread. 

When the hair has been removed, it is easy to 
see the diseased places, which appear dry, scurfy, 

* Small round-pointed, curved, eye scissors are very 
useful for keeping the hair closely cut. 

The miniature horse-clipper is also a convenient instru- 
ment for rapidly cutting the hair short. This can be ob- 
tained at the instrument makers ; and medical «men, who 
often have ringworm cases to treat, will find it well worth 
procuring. 



QENSBAL DIRECTIONS. 107 

and of a dull greyish, or leaden hue. The head 
should then be thoroughly washed with carbolic 
acid soap, and all scabs, scales, and sebaceous 
matter removed. 

If the patches are not very extensive, it is 
advisable to epilate as many of the diseased hairs 
as possible, by means of a broad-pointed pair of 
forceps. 

The general directions about hair-cutting, caps, 
washing, application of remedies, prevention of 
spreading, crosts and scabs, epilation, and pre- 
ventive ointments and lotions, &c., virill be found 
at the end of Chapter YIII. 

They are placed at the end for convenience of 
reference, but should be consulted before any 
treatment is adopted. 

Recent bingwobm may be divided into two 
classes: — 

Firstly f when there are only two or three small 
and very recent places. 

Secondly, when the disease is extensive, and 
must have existed some little time before coining 
under treatment. 



108 BECENT bingwoem: its tbeatment 



Tbeatment of Yebt Recent Ringworm. 

We shall now consider the treatment of a case 
which has evidently existed only a few days^ or a 
week or two. No time should be lost in having 
the head well washed fii*st^ bat the hair should be 
cut on the patch or patches, and some parasiticide 
or vesicant, at once applied ; later on the hair can 
be cut moderately short all over the head, and the 
scalp washed and dried ; then a preventive lotion 
or ointment should be used all over. 

Ghbysophanic acid (Chbtsabobin) in Ghlobo- 
fobm.^ I have been trying for some time past to 
find out what vehicle penetrates most deeply into 
the hair-follicles, and believe it is chloroform. 
Chrysophanic acid — or rather chrysarobin — is a 
very good parasiticide ; and though it is barely 
soluble in spirit and ether, yet it is soluble in 
chloroform. Chloroform will also dissolve the 
fatty and sebaceous matter out of the follicles, and 
thus allow the parasiticide dissolved in it to pene- 
trate deeply. During the last year I have used a 
solution of seven grains of this acid to the ounce 
of chloroform to many cases of recent ringworm, 

• Vide "Therapeutic Memoranda" by Alder Smith, 
Britiih MedicalJournal, Nov. 1st, 1884. 



BY CHBtSOPHANIC ACID IF CHLOEOFORM. 109 

where there have been only one or two places, 
not larger than a shilling or a two-shilling piece. 
This treatment is, I think, more likely to be sac- 
cessfal than blistering. 

The small places should be carefally marked out 
by cutting the hair very closely upon them, and 
the chloroform solution should be well pressed and 
dabbed into the places with a minute sponge mop 
for five to ten minutes two or three times a day, 
according to the amount of irritation produced. 
The aim of this treatment is not to produce scabs, 
but to get the solution to penetrate to the bottom 
of the follicles. The sponge mop should not be 
much larger than a large pea ; and it should be 
continually dipped into the chloroform bottle, as 
the solution soon evaporates whilst it is pressed 
into the diseased spot ; leaving the yellow acid 
dry upon it. 

The places should be well washed every morning 
with hot water and soap, to remove all sebaceous 
matter and scurf, and the whole head about once 
a week. Great care should be taken to wipe off 
the acid from the places, and not to rub it into the 
surrounding part of the scalp, and thus stain the 
head ; also that the lotion does not run on to the 
forehead or into the eyes, and that the person 
using it does not inhale the vapour. It is always 



110 BBCSNT singwobh: its tbkathent. 

advisable to give full directions to the nurse abont 
the care necessary in using such a potent remedy^ 
and only to employ it to small places. It is also 
well for her to keep her face away from the sponge^ 
and to use the solution in a current of air^ and not 
in a small and closed room. 

It is always desirable to use some parasiticide 
all over the scalp the first few weeks of treatment^ 
no matter how small the ringworm patch may be. 
I generally employ the boracic acid and spirit lo- 
tion^ a lotion of hyposulphite of soda (two drachms 
to the ounce) J or a lotion containing an eighth part 
of liq. sodsB chlor.. The preventive lotion should 
be dabbed all over the head once a day. 

Epilation is not necessary^ but if practicable it 
certainly helps the penetration of the remedy. 

The hair should be kept, closely cut upon the 
patches until the new downy hair appears, which 
is generally in about two or three months ; but the 
remedy or some other parasiticide should be con- 
tinued till all the diseased stumps have come out. 

It is not advisable to employ this treatment if 
the disease is extensive^ or if a patch extends 
nearly to the forehead^ as staining is sure to 
happen. 

If chrysophanic acid causes too much irritation 
and forms scabs^ it must be used only once a day^ 



TBBATMENT BT VESICANTS. Ill 

and boracic acid in spirits of wine and ether should 
be used as well^ two or three times a day. I con- 
stantly use chrysophanic acid in chloroform and 
boracic acid in ether and spirit at the same time^ 
and order a saturated solution of boracic acid in 
spirit all over the head^ as a preventive. 

If too much irritation is still kept up, or the 
case is not progressing favourably, the former 

m 

lotion should be left off, and one of the follow- 
ing treatments adopted. 

Boracic acid spibit lotion. — This may be ap- 
plied {Vide Chapter VII.) to a few as well as 
to many places ; and there is no doubt it is an 
excellent treatment, if the directions given are 
thoroughly carried out. Boracic acid may also be 
dissolved in chloroform and spirits of wine. 

Salicylic acid can be employed from forty to 
sixty grains to an ounce of spirit and ether, or 
chloroform (Fwie Chapter VII.). 

Vesicants. — ^A good vesicant used at a very earljr 
stage, will sometimes destroy the fungus — viz., 
when the conidia have not had sufficient time to 
penetrate deeply into the follicles — but it very 
rarely alone effects a cure, except when applied to 
a place evidently only a few days old; and it 
certainly delays, by forming scabs, the employment 
of remedies which penetrate into the hair-follicles. 



112 BECEKT RING WORM : ITS TBEATMKNT. 

I have 80 many times failed to stamp oat small 
places of recent ringworm, even with strong 
glacial acetic acid, etc., that I now think that 
it is often a waste of time to employ them, and 
that penetrating lotions are to be preferred. 

The nsual old plan of treatment was to blister 
first with liq. epispasticas, or with glacial acetic 
add. If the latter is nsed, it is better to have 
some corrosive sublimate dissolved in it, about four 
to six grains to the ounce. Blistering large sur- 
faces is very painful, and not without risk ; and, 
in my opinion, is quite out of the question with 
young children. Light-haired, ill- nourished, and 
strumous children do not bear blistering well, and 
it 18 well to avoid iL If a blister be employed, some 
preventive should be applied all over the head at 
night. 

When the blister has risen it should be pricked, 
and the fluid let out, or else it will coagulate, and 
form a gelatinous mass. A double thickness of 
lint, saturated with sulphurous acid lotion (equal 
parts of sulphurous acid and water), can be placed 
over the patch. The lint should be constantly 
wetted with the lotion, and a piece of oil-silk 
kept over it for two or three days. After blister- 
ing, it is advisable to pick off any scab, and then 
to epilate freely, removing as many of the diseased 
hairs as possible. 



BY COBBOSIVS SUBLIMATE. 113 

This plan of blistering sometimes cures places 
of recent ringworm, but it must not be relied upon 
alone. Some parasiticide (as carbolic glycerine) 
will generally have to be employed for two or 
three months, in order to destroy all the conidia, 
and until the new downy hair commences to 
grow. 

CoBEOSiVB SUBLIMATE (pcrchloride of mercury) 
is very cleanly, has no unpleasant odour or colour, 
and is undoubtedly one of the best remedies for 
ordinary recent ringworm. It may be used, to 
small patches only, dissolved in spirits of wine 
(one to three grains to the ounce), in acetic acid 
(two to four grains), or in lard as an ointment 
(two to five grains). 

It should rarely be employed in extensive ring- 
worm, especially if the places are excoriated and 
sore ; and great care must be exercised, as it is so 
poisonous. 

If used in an ointment, it should always be dis- 
solved in a little spirit, before it is mixed with the 
lard; but the best plan is to use the alcoholic 
solution, and to thoroughly dab it into the small 
patches two or three times a day. 

Caebolic glycerine. — Carbolic glycerine is a 
very good remedy. The strength should be 
varied according to extent of surface to which it is 



1 14 SICIHT SIKOWOSM : ITS TSUmniT 

applied^ the age of the patient^ and the effect pro* 
dnced. 

In the case of a child under five years of age^ 
we can commence with one part of carbolic acid^* 
to fonr or five of glycerine; if six or seven, one 
part to three or fonr of glycerine ; if eight or ien, 
one part to two or three; iS over ten, one to two 
of glycerine. The scalp will very rarely bear 
equal parts three times a day without scabbing. 

The glycerine penetrates freely^ and carries the 
acid to the conidia. It is cleanly^ and seldom 
painful. 

In employing carbolic glycerine^ the most im- 
portant points to remember are : — to nse it often^ 
three times a day^ if possible ; and to have it well 
rubbed and pressed into the places with a smaU 
sponge mop.t Nnrses generally shirk this duty ; 
therefore the doctor must take care to see that 
this preparation is properly applied. 

Eemedies of moderate strength^ frequently used 
with friction^ are always preferable to strong and 
vesicating ones. The great object in this treat- 
ment is to get the carbolic glycerine well into the 
follicles^ and not to produce scabs^ which only 
hinder the parasiticide from entering into them. 

* It is advisable to order Calverfs carbolic acid, No. 2. 
f These mops can be made by tying a small piece of sponge 
on to the end of a penholder. 



BY ACETIC ACID^ AND COSTSB^S PASTE. 115 

When using carbolic acid in any form, it some- 
times — but very rarely — happens that the child 
appears drowsy after its use, as if some portion 
had been absorbed. If any symptoms indicative 
of absorption appear, it is better at once to dis- 
continue its use for a day or two, and then to 
reduce the quantity, or to try some other para- 
siticide. 

Acetic Acid. — Strong (not glacial) acetic acid 
is a first-class remedy for smaU and recent patches 
of ringworm, especially if two grains of corrosive 
sublimate are dissolved in the ounce of acid. 

Acetic acid is a painful application if constantly 
used, but it is a very efficient parasiticide. It can 
be applied every day, and the scabs removed as 
soon as they form, with any diseased hairs sticking 
to them. It is sometimes advisable to use acetic 
acid occasionally, when other parasiticides are 
employed. 

COSTBE^S PASTE : — 

B; lodinii, • • • Sij. 
01. Picis Liq., ad | j. M. 
(The colourless oil of tar). 

When there are only two or three recent places, 
Coster^s paste may be applied with a brush, and 
then small pieces of lint should be placed over the 
paste. This will produce a scab, which may be 

i2 



116 BECSNT binqwobm: its treatment. 

removed in a few days, with the stamps adhering 
to it j and then, after epilation, some more paste 
can be used. Coster's paste can be repeatedly 
applied, till all the diseased stamps are removed. 

Mr. Morrant Baker nses creasote with the 
iodine, instead of the ordinary Coster's paste. Of 
coarse this preparation has a strong, and to most 
persons a very disagreeable smell, bat it is very 
efficacioas for ordinary small places of ringworm. 

Gk)A POWDER AND CHRYSOPHANIO ACID — CHBY- 

SAROBiN. Grennine Bombay Goa powder is a 
favonrite remedy for recent ringworm, especially 
when there are only one or two patches ; bat I 
think chrysarobin (or Goa powder) dissolved in 
chloroform, is better than the dry powder. {Vide 
pages 108 and 126)."^ 

* The other remedies mentioned in the next chapters — 
especially oleate of copper — may be employed for small 
places, as well as for extensive ringworm. 



EXTENSIVE AND BECINT BINGWOSM. 117 



CHAPTER VII. 

The Teeatment of Beoent Binowobm of the Head^ 
WHEN THE Disease is not confined to a few 

SMALL PLACES: AND OF iKPEnGINOUS EcZEMA 
AND BlNGWOBM. 

ExTENSIVB and BeCENT BlNGWOBM. 

In such cases^ either (he affection has not been 
recognised in the early stage^ and therefore has 
not been under any treatment^ or the case has 
been subjected to treatment^ perhaps for two or 
three months^ without any good effect being pro- 
duced. If one remedy has failed to influence the 
disease after a fair trial of two months^ or if the 
ringworm has spread while under treatment^ it is 
certainly better to try something else ; as there is 
no doubt that a parasiticide that will succeed with 
one child will often fail with another. 

Only a few good plans will be considered^ as it 
is quite useless to notice all the various remedies 
that have been recommended for ringworm. Their 
very number shows that they all fail at times in 
curing this disease. 



118 Bscnrr and xxtensivib binowoeh: 

One of the most recent treatments is: — 
BOBACIC ACID LonoN: — * 

^ Acid. Boracioi, • • 3 iv., vel q. s. 
MOi. Siilph.t (Meth.) J v. 
Sp. Yini Beet., ad • ^ xx. 
Ft. Bolutio satnrata limpida. 

Tliis lotion is a saturated solution of boracic 
add ; and of all treatments it is the most agree- 
able, as it causes no pain or irritation, and can do 
no possible harm. It is very often successful ; and 
is certainly a favourite remedy. 

I have seen ringworm (both recent and chronic) 
more quickly cured by thia lotion than by any 
other parasiticide — even in two months or less, 
which is a rare event except with croton oiL Of 
course, like all other treatments, it ofcen fails to 
influence the disease, yet it is well worth try- 
^g> for, if it cure at all, it does so quickly and 
thoroughly, and rarely leaves a lot of stumps to be 
removed by other means. If the ringworm is 

* First suggested by Dr. Cavafy ; see Brit, Med, Jour,, 
June 24th, 1882. 

f Methylated ether is cheaper than pure ether, and equally 
efficient. Methylated spirit mmy be employed, but the scent 
afterwards is far from pleasant. This may be slightly obriated 
by adding :— 01. Rosmar. Ezot, 5iii. 



TBEATMSNT BY BOBACIC ACID. 119 

rapidly cnred^ it is generally dae to the part be- 
coming very dry, and the stumps falling out. 

There i^ no doubt that the accumulation of 
sebaceous matter and epithelial debris, and the 
plugging of the hair-follicles by the diseased 
and swollen hairs, prevents the penetration of 
remedies into them. The great object of all 
treatment is to bring the parasiticide into contact 
with the deeply- seated fungus; and this can very 
often be accomplished by using a lotion that will 
remove the fatty materials out of the follicles, 
and thus allow the parasiticide dissolved in it to 
penetrate to the bottom of them. 

Treatment. — ^The places having been well 
marked out, or most of the hair having been re- 
moved, they should be well washed with hot 
water and soap to thorovyhly remove all scurf and 
sebaceous matter from the surface of the scalp. 
This washing of the places should be repeated 
every morning, to remove the accumulation of 
fatty material and boracic acid, which is left by the 
evaporation of the lotion on the skin. 

It is essential that this deposit be removed each 
day, and that no accumulation of scurf and fatty 
matter be allowed to remain over the hair-follicles. 
This part of the treatment is often shirked, and 
the lotion is applied over a layer of unremoved 
sebaceous material, which is a waste of time. 



120 BECENT AND EZTENBIYX BINOWOBM : 

After well drying the head^ the spirit should be 
well pressed and dabbed into the hair-follides^ 
with a small piece of fine sponge, for ten minntee. 
The lotion rapidly dries^ and leaves a white 
deposit on the head. It should be used at least 
three times a day; but^ I firmly believe^ the 
oftener it is employed the better^ and I have had 
very successful results by having it applied five or 
six times in the course of the day^ or as often as 
there has been the opportunity. Care should be 
taken not to use the lotion too near a lights as it 
contains so much ether ; and the sponge should 
be thoroughly freed from grease^ from time to 
time, by washing it in a little soda and water. 

The first few weeks, the lotion should also be 
used all over the head, as a preventive^ once a 
day ; and if any fresh places develop, they should 
be marked out by closely cutting the hair. 

While this treatment is carried out, no pomade 
must be used, and the hair on the places should 
be kept closely cut, till the new downy hair com- 
mences to grow; which is generally in two or 
three months. 

Sometimes this application causes such drynesSj 
that the stumps rapidly fall out and leave tem- 
porary, smooth, bald places, much resembling 
alopecia coming on from other causes. Thus we 



TREATMENT BY BOBACIC ACir« 121 

may get a complete mixture of the two diseases, 
before noticed on page 65. If this should happen, 
it is most fortunate ; and when all the diseased 
stumps have come out, a stimulating lotion should 
be used, as turpentine, tincture of iodine, or a lotion 
with cantharides, similar to the one recommended 
for alopecia, — Vide Chapter XI. — and in a few 
weeks, the new downy hair will appear. 

This is a new and excellent way of epilating, 
and if this lotion would always cause these smooth 
bare places, it would be the surest and best 
remedy for ringworm ; but unfortunately, at times 
it makes no impression upon the disease ; there- 
fore if after two or three months there is no new 
hair, and the stumps easily break off instead of 
coming out, and are still saturated with fungus, it 
is advisable to change the treatment. 

Mr. Malcolm Morris — in writing on the treat- 
ment of ringworm — advises thymol (half a 
drachm), ether (five drachms), and spirits of wine 
(two drachms and a half); or five grains of 
thymol in one and a half drachms of petroleum oil ; 
and remarks as follows : — 

''There is a disease of the scalp known as 
seborrhoea sicca, the chief characteristic of which 
is the falling out of the hair. This is caused by 
the absence of the natural fat in the sebaceous 



122 BBCINT AND XXTENSIYE BIHGWOBIC : 

matter. It is cored by stimulating the glands to 
action, and by adding fat artificially. In the 
ringworm patch, we want the diseased hairs to 
fall oat ; and by producing a condition similar to 
seborrhcea sicca — that is by making the part very 
dry — we can actually produce this effect. Instead 
therefore of epilating by means of forceps — which 
is useless, as the hair breaks at the neck of the 
follicle, leaving the diseased part behind — we 'can 
epilate by dissolving the fat, and thus loosening 
the hair.^'* 

I folly agree with this statement ; and thus it is 
that boracic acid, salicylic acid, menthol, thymol, 
and other remedies dissolved in alcohol, ether, and 
chloroform, often eradicate ringworm much more 
quickly than fatty ointments. 

Oleats of Coppsb Ointmbnt. — The marvellous 
results which have lately been ascribed to Dr. 
Shoemaker's preparation of oleate of copper are 
unprecedented, but I am sorry to say, in the ex- 
perience of some who have recently tried this 
preparation, it has been found to fall short of 
what might have been expected, and prefer- 
ence is still given by them to the oleate of 
mercury. There is no doubt that oleates pene- 
trate very well — as I have always maintained — 

* Britiih MedicalJoumal, June 17th, 1882. 



TREATMEKT BT OLEATE OF COPPEB. 123 

and that oleate of copper is an excellent penetrat- 
ing parasiticide for recent ringworm : but I am 
afraid it is not^ what some have described it^ 
"almost a specific" for this troublesome com*- 
plaint. At any rate there is no risk in nsing it^ 
and if the boracic acid treatment fail, the copper 
preparation should be employed; and in many 
cases I now give it a fair trial first. 

Dr. Weir,* in an article on oleate of copper, 
remarks : — '' We all remember the old fashioned 
cure for ringworm, consisting of a copper penny 
dipped in vinegar.'^ " The legitimate successor 
of the ' penny-vinegar cure ^ (ointment of oleate 
of copper), the newer preparation not only con>. 
bines all the essentials of the latter, presented in 
a neat and available form, but offers the means of 
effecting cures with far greater uniformity of 
results than has ever been obtained before, no 
matter what the remedy." 

The details of the treatment will be found in 
Chapter VIII. on Oleates. 

Carbolic Acid, Citbinb, and Sulphur Oint- 
ments, t — ^When a moderate or a large extent of 

* New York Med. Jour., Aug. 30th, 1884. 

f Fide '* Ringworm (of the head) its Diagnosis and Treat" 
ment." The Lancet, Jan. 10th, 24th, Slst, 1880; and A 
Report of the treatment of a very extensive outbreak of ring" 
worm, hy Alder Smith, Brit. Med. Jour., Dec. 16, 1882. 



124 RECENT BINQWOBH: ITS TBEATMEKT 

surface is involved^ and the disease has existed 
only one or two months^ the following ointment can 
be employed. In the last edition of this work it was 
recommended as the best treatment for extensive 
and recent ringworm^ bat it has now been super- 
seded by oleate of copper made by the new pro- 
cess of precipitation^ and by boracic acid lotion. 

B; Acid. Carbolici,* . . ? 
{Calvert's No. 2.) 

Ung. Hydrarg. Nitrat., ?t 

Ung. Sulphuris, . • • ? M. 

This ointment as a rule causes very little pain^ 
and is very effectual. 

In writing a prescription for it, it is important 
to tell the chemist not to apply any heat, and to 
mix the carbolic acid thoroughly with the sulphur 
ointment first, and to rub in the citrine ointment 
last. 

* The pure crystallised carbolic acid must be employed, 
or the ointment will change colour. 

t It is most important that the citrine ointment should be 
quite free from any excess of nitric acid. Most ointments in 
common use turn brown or black when the carbolic acid is 
mixed with them. As it is very difficult to find a citrine 
ointment of this description, I mention here that Messrs. 
Corbyn and Co., (of 300 Holbom, London), keep one speci- 
ally prepared for making this compound ointment. 



BY CARBOLIC, CITBINE, AND SULPHUR OINTMENTS. 125 

If this preparation tarn a dark brownish colour, 
within a week, there is certainly something wrong 
with the purity of the citrine ointment, as equal 
parts, mixed as advised, will keep of a yellowish 
slightly brown colour for a week or two. 

It is advisable to have this ointment made fresh 
every week or ten days. 

Proportions. — ^These vary according to the age 
of the patient, and the extent of surface to which it 
is to be applied. If used all over the scalp, it must 
be weaker as regards the carbolic acid, than if 
rubbed into a few places. 

For a child under five years old, we may order 
about four parts of sulphur ointment to one of 
each of the other ingredients; while, for one 
between six and seven, three parts of the sulphur 
ointment ; if eight or ten, only two parts : or if 
over eleven, about one part of carbolic acid to one 
and a half of each of the other ointments. 

As a rule, more citrine ointment can be used 
with advantage than carbolic acid ; so it is advis- 
able to commence as above, and then to increase 
the amount of citrine ointment, if the scalp will 
bear it. Equal parts of all three can generally 
be applied to individual patches, in children over 
ten. 

Treatment, — After the head has been prepared 



126 RECENT AND EXTENSIYB SINGWOBM : 

as directed for treatment^ the ointment should be 
well rabbed in two or three times a day, the head 
washed once or twice a week, and all crusts care- 
fnlly removed before it is again applied. 

If a weak ointment is used all over the scalp to 
prevent the disease from spreading, it is desirable 
to employ a stronger one to the individual patches. 

The scabs that usually form during this treat- 
ment, will turn a dark-brown colour, especially 
if the ointment be used after being made a week. 
Sometimes this remedy will cause the stumps to 
become loose in the follicles, and even produce 
slight kerion, and thus rapidly cure the disease. 

Carbolic Glycerins may also be used for ring- 
worm, if not too extensive {Vide page 113). 

GoA Powder, Chrysophanic Acid, Ghrysarobin. 
(Araroba, Poh di Bahia), — If either of these 
remedies be used for extensive ringworm, the 
Bombay Goa powder (Messrs. Kemp and Co., 
Bombay, — called " Chrysarobine '^ is to be pre- 
ferred, as it causes much less irritation and staining 
than the ordinary Goa powder, end chrysophanic 
acid (or rather chrysarobin) ointment. If this 
special powder be used with proper care, no unto- 
ward result will happen, as is so often the case 
with chrysophanic acid ointment, and the ordinary 
Goa powder. However, it is rarely of use if the 



TREATMENT BY GOA POWDER. 127 

disease has existed some little time; yet^ if the 
former parasiticides have failed to cure the dis- 
ease^ and oleate of mercnry (which is an excellent 
remedy for chronic ringworm) is objected to, 
'' chrysarobine '' is well worth a triaL 

The objections to the use of these remedies are as 
follows: — they stain and spoil everything with 
which they come into contact, collars, pillow-cases, 
linen, etc. ; the hair becomes a dull, pnrplish-red, 
or brownish-red colour; and if the preparation 
gets on to the face, it causes great irritation, 
red-staining, and roughness of the skin; if it 
reaches the eyelids, they become oedematous, and 
the eyes inflamed. Although every precaution 
may be taken, children generally manage to get 
the powder, or the acid, on to their foreheads and 
faces ; often by first scratching the irritated scalp 
and then by rubbing the face and eyes. After 
nsing the remedy for a short time, pustular eczema 
is frequently set up on the healthy portions of the 
scalp. The places themselves may not become 
irritated, but the powder seems to collect about 
the hairs round the patches, and to cause impeti- 
go. The glands at the back of the neck generally 
enlarge, and become painful. I have constantly 
seen eczema, and even impetiginous eczema, 
caused by the use of chrysophanic acid, and of the 
ordinary Goa powder sold in this country. 



128 BECENT AND EXTENSIVE BINGWOBM: 

Messrs, Kemp and Co/s '' Chrysarobine " is a 
good parasiticide^ if it can only be brought into con- 
tact with the conidia ; bat I have often noticed that 
this remedy appears to cure cases of ringworm by 
destroying all the fangas within its reach. But, 
it does not (unless dissolved in some medium such 
as chloroform) petietrate deeply into the follicles ; 
and though the broken hairs, removed from the 
surface of the scalp, may appear to be free from 
fungus under the microscope, yet if the stumps 
are carefully extracted from some depth, and the 
deep fractured end examined, plenty of conidia 
are generally to be found. Such cases are fre- 
quently certified as cured ; yet, in a week or two 
after the parasiticide is discontinued, the diseased 
stumps again make their appearance. Often, 
after chrysophanic acid has been used, the follicles 
get marked out, as so many black dots, and the 
edges of the minute bits of scurf get coloured 
dark red, so that it is most difficult to determine 
whether any diseased stamps are present or not. 

Therefore, it is advisable not to certify a case 
of ringworm to be well, after the Goa powder or 
chrysophanic acid treatment, until at least two or 
three weeks have elapsed since the application of 
the remedy, and until the new downy hair has 
appeared. 



TREATMENT BY CHEYSAHOBINE. 129 

" Chrysarobine " is all but useless in the exten- 
sive^ and chronic varieties of the disease ;* and^ in 
my opinion^ should only be used for small and 
recent patches. 

Treatment with *' Chrysarobine/' — The hair 
should be very closely cut on the patch or patches^ 
the part well washed with soap and water^ and 
then bathed with hot water. While the places 
are still moist^ a little 6oa powder should be well 
rubbed into them with the tip of the finger^ pro- 
tected by an india-rubber finger-stall. The tip of 
the finger can be dipped, now and then, into a 
little hot water, in order to keep the powder 
moist. The rubbing should be continued for five 
or ten minutes, two or three times a day ; the 
places being first thoroughly bathed with hot 
water. No excess of powder should be left on the 
patches, or it may fall into the eyes. Any excess 
at the outer edge of the patch, among the healthy 
hairs, should be especially avoided, as it may 

* A report by Dr. Crocker will be found in The Lancet of 
Jan. 27tb, 1877, on tbe use of Goa powder, in which he does 
not speak very favourably of the value of this parasiticide. 
<* Of the whole twenty (cases) two were cured completely " — 
'■* in seven there was certainly improvement " — '* the remain- 
ing eleven cases were only slightly improved, although the 
treatment was kept up for at least three months, and even 
longer." 

K 



130 BECENT AKD BXTENSIVB EINGWOBM : 

cause impetiginons eczema upon the healthy por- 
tions of the scalp. If much irritation occur^ the 
powder should be discontinued for a few days^ or 
some other treatment adopted. 

Salictlio acid is another very good parasiticide. 
It may be used in an ointment— strength from 
twenty to sixty grains to the ounce — or better in 
a lotion with alcohol and ether. Chloroform may 
also be added^ if the patches are not too extensive. 

It is also a convenient preventive to use all over 
the head^ when employing croton oil^ or other 
strong remedies to a few small places; but it 
sometimes causes irritation^ and scales to form 
over the head. 

Gbeasotb may cure cases of ringworm which 
have resisted many other remedies^ but it is di£S- 
cult to employ, as it renders the house almost 
uninhabitable by its strong smell, and patients say 
the remedy is worse than the disease. 

It can be appUed undiluted to small places, but 
I prefer to mix it with two or three parts of lard, 
or oil of tiurpentine {Vide page 132). 

SuLPHUBOUs ACID is also a good application, 
if pi-operly and continually applied. Pieces of lint 
saturated with sulphurous acid or sulphurous acid 
with equal parts of water, should be placed over 
each patch of ringworm. The whole should be 



TBSATMENT BY THTHOL. 131 

fixed in position with an oil- skin cap. It is im- 
portant to constantly soak the lint nnder the oil- 
skin with the sulphurous acid lotion^ not less 
frequently than once an hour. At night-time^ as 
it is impossible to constantly apply it, hyposul- 
phite of soda (two drachms to the ounce) lotion 
may be used. 

Some advise glycerine with the sulphurous acid : 
this is^ I think^ a mistake, as the sulphurous 
acid and water evaporate and leave the glycerine ; 
and thus^ by degrees^ the lint and parts get satu- 
rated with glycerine, instead of sulphurous acid. 

It is important to remember that unless the 
lint is constantly wetted with the sulphurous acid, 
and an oil-skin cap is worn, it soon becomes a 
valueless remedy from rapid evaporation. Sul- 
phurous acid should be freshly made, as it soon 
loses strength, both by evaporation^ and by the 
acid becoming oxidised into sulphuric acid^ which 
is an irritant, and not a parasiticide. 

Thymol and Menthol may be used dissolved 
in alcohol and ether, with or without chloroform, 
about thirty grains to the ounce. They have 
been much recommended by Mr. Malcolm Morris.* 

These parasiticides are non-irritating, and very 

* Clinical Lecture on Ringworm. — The Lancet, Feb. 12th, 
1881; and BrU. Med, Jour., June 17th, 1882. 

k2 



132 KECBNT BINQWOBM : 

cleanly. I have used them both in recent and 
in chronic ringworm, but cannot say I think they 
are as efficient as boracic or salicylic acids {Vide 
page 121), or the ointment of oleate of copper. 

TiNcruBB OF IRON. — Stroug perchloride of iron, 
applied now and then, combined with a constaot 
application of tincture of iron, is sometimes found 
to be a good remedy for ringworm. 

Liniment and tincture of iodine. — If iodine 
be used, it is well to employ Coster's paste, in 
which the iodine is dissolved in colourless oil of 
tar. This penetrates better than the simple tinc- 
ture, or liniment, which will rarely cure ringworm 
of the head. 

Turpentine is at times very useful, and as it 
penetrates freely into the hair-follicles, many 
parasiticides may be dissolved in it, viz., creasote 
(one in four), thymol, iodine, &c. Turpentine 
and creasote is a very good application for ex- 
tensive ringworm, but the great objection to its 
use is the odour. 

Boko-Glycbride (Barflfs) has lately been advised 
for ringworm, and may be rubbed in pure or diluted 
with one or two parts of glycerine. Its merits 
are that it is non- poisonous, and can be borne by 
the most irritable scalp ; therefore its chief use is 
for cases that will not bear ordinary parasiticides, 
and as a preventive lotion. 



TBEATMENT WHEN TENDER AND 80BE. 133 

The two following oiDtments were favourite 
remedies of the late Dr. Tilbury Fox : — 

No. 1. B; Cupri Sulphat., . gr. x. ad xx. 
01. Junip. Pyrolig., . . . 3 iij. 

Sulphur., 3 iij. 

Hydrarg. Ammon., gr. v. ad xx. 
Adip. Benzoat., . . . . |j. M. 

No. 2. B; 01. Junip. Pyrolig., ... 3 iij. 

Sulphur., 3 iij. 

Tinct. lodinii, , . . . 3 iij. 
Ac. Carbolioi, . nx xx. ad xl. 
Adip. Benzoat., . . . . ^j, M.. 

The latter is useful in cases of irritable scalp. 



Treatment when the Scalp becomes Tender and 

Sore. 

Sometimes the places get very tender and sore 
(generally with crusts), under ointments, carbolic 
glycerine, chrysarobine, or other treatment, and 
the child cannot bear any rubbing in of the 
remedy, as it causes too much pain. 

With the parasiticides now recommended, this 
complication will rarely occur; if it should happen^ 
it is advisable to discontinue the application for 
a time, and to adopt some non-irritating treat* 



134 TBIATHIHT OV CSUSTIKG 

ment, especiaUy boro-glyceride^ the boracic acid 
lotion^ or a very dflote oleate of copper ointment. 
Boro*glyoeride is certainly one of the best ap- 
plications to employ if the scalp is tender and sore» 
especially if there is any tendency to impetiginous 
eczema. In suitable cases one cannot speak too 
highly of it^ as it may be used to prevent the ex- 
tension of the disease^ while constitutional treat- 
ment is employed to render the scalp capable of 
bearing stronger parasiticides. 



Tbsatment of Cbustino Impstioikous Eczema^ 

WITH Ringworm. 

At times^ ringworm partakes of the character 
of a rapidly spreading impetiginous eczema (de- 
scribed^ p. 20). It sometimes happens — ^but very 
rarely — that most parasiticides set up this trouble- 
some variety^ and the ringworm rapidly spreads 
under ordinary treatment^ with crusts^ and pus 
oozing from beneath them. Such cases are very 
difficult to manage^ and they sometimes spread in 
spite of efficient treatment. 

Tiu&ATMENT. — It is essoutial that the impetigin- 
ous eczema should first be treated and curpd. If 
the places are at all extensive^ it is of the utmost 
importance that all the hair should be cut off. If 



IMPSTiaiKOUS ECZEMA AND BINQWOBM. 135 

only a few patches exists the hair must be cut 
from them^ and for an inch ronnd^ and the rest of 
the hair should be kept shorty about an inch long. 
All the crusts must first be removed by soaking 
them in oil^ in which may be a little menthol^ and 
by poulticing them at night. After the places have 
been cleaned^ white precipitate ointment is one of 
the best applications ; if it cannot be borne full 
strength^ it should be diluted^ and a little oxide 
of zinc may also be added. If this cause irrita- 
tion^ simple white vaseline should be applied^ and 
by degrees^ a little white precipitate added. 
Boro-glyceride is generally very useful and can be 
employed till the general health is improved. 
General treatment is essential — salines and aperi- 
ents^ with simple and good food, as this variety 
is often due to improper feeding. 

When the eczema has abated^ and all the crusts 
have been removed by poulticing or bathing with 
warm water, and all the inflammatory symptoms 
have passed away, the best treatment to try, is 
the boracic acid lotion, which rarely causes any 
irritation, and has even proved effectual when 
ringworm has been spreading with crusts. 



13G CBBONic bingwobm: its tbbatuent 



CHAPTER VIII. 

Tab Tbkatment op Cheonic Rinqwobm : Br the 
Olisatbs or Mebcuby and Copfeb. 

There are many cases of ringworm which ordinary 
remedies will not care. Sometimes the disease 
has existed unknown^ or untreated^ for many 
months before it is brought under the doctor^s 
care ; or it may have been well treated for three or 
four months without apparent benefit. 

The treatment of these chronic forms of ring- 
worm will now be described ; as well as the treat- 
ment of those cases^ in which the disease has been 
attended to until the hair has grown again^ and 
then the children have been neglected for months^ 
or even years (because they were supposed to be 
well)^ until some special reason has brought them 
under the notice of an expert. 

As before mentioned^ the difficulty in such 
cfises^ is not to find some parasiticide that will 
destroy the ringworm fungus, but to bring the 
remedy into contact with it. In recent ringworm 
the conidia, as a rule, only penetrate a certain 



BT THE 0LBATK8 OF HKECUBY AND COPFKE. 137 

distance into the follicles, and therefore the dis- 
eaae is sometimes rapidly cured by any parasiti- 
cide; but after a time they penetrate to the very 
bottom of thefoUielea (which it must be remembered 
are even behw the true skin], and into the bulbs 
of the hairs. (Vide Fig. 1). 



Fio. 1. 

Perpendicular section through the Bcalp, with two hair- 
follicles, showing the bulbs, the relative depth of the fol- 
licles, BDil also iudicating the great depth to which the 
conidia may penetrate. (Kolliker). 

It is therefore very difficult to reach the fungus 
by any application rubbed into the surface of 
the scalp, as the diseased stamps plag the follicles 
into which we require the parasiticide to enter. 
And it is easy to understand that a limit is often 
reached in the follicles, below which the ointment. 



188 CHBONic bingwobm: its tbbatmsnt 

lotion^ etc., cannot penetrate^ as the diseased 
stnmps, with the fungus^ are constantly growing 
towards the surface of the scalp^ while the para- 
siticide is soaking towards the bottom of the fol- 
licles. Therefore, when the penetrating action of 
the remedy is equalled by the rate of growth of 
the hair, a point is reached below .which the fan- 
gas still grows laxoriantly, althoagh the parasiti- 
cide may be steadily rubbed into the follicles for 
months. This is the reason why some cases of 
recent ringworm, though under efficient treatment, 
pass into the chronic variety, and defy all ordinary 
curative means at our disposal. The parasiticide 
is not at fault, but the penetrating power of the 
vehicle. 

Moreover the stumps are so diseased, and there- 
fore so brittle, that they cannot be extracted 
entire by epilation, but break off, and leave the 
root part and upper part of the bulb swarming 
with the fungus in an active state. {Vide Plate 
II.). 

^^A remedy must therefore be selected that 
will penetrate deeply into the follicles, and I think 
there is but little doubt that oleate of mercury is 
the best application we possess for this purpose.'^ 

These were the words used in the last edition of 
this work, but since that was published two parasiti- 



BY BORACIC ACID LOTION. 139 

cides have been found to be very nsefal for chronic 
ringworm, besides oleafce of mercury. I refer of 
course, to boracic acid, and oleate of copper. The 
former I have so often seen cure inveterate cases 
of chronic ringworm, which had even resisted 
oleates, that I generally give this lotion a fair trial 
before advising oleate of mercury. The great 
advantage of the solution of boracic acid is, that 
if it cure at all, it generally does its work com- 
pletely, and we have not a number of stumps left 
which necessitate the croton oil treatment before 
they can be removed. The lotion is used in the 
same way for chronic as for recent ringworm. It 
has been while using it to chronic cases, that I 
have so often seen bald places resembling alopecia 
form ; and thus, many cases which had resisted 
everything else for years, were cured. In the 
chronic form it is advisable to mark out all the 
places by closely cutting the hair over them, and 
only to order the rest of the hair to be shortened to 
about half an inch. By doing this, all the time 
and material can be spent on the diseased places, 
which cannot be dabbed too often with the lotion. 
This new way of causing epilation, by drying the 
places and removing all the sebaceous matter, 
is a very excellent one. 

For directions see page 119. 



140 CHRONIC KINOWOBM : ITS TREATMENT 



Treatment by the Oleates of Mercury and 

Copper. 

I have constantly seen oleate of mercniy cure the 
most inveterate^ and extensive cases of ringworm, 
which had existed for years^ and on which all 
sorts of other remedies had been tried in vain. 
It hardly ever causes any pain^ and there is no stain- 
ing, or injury to the skin ; and it certainly pene- 
trates freely into the follicles^ hairs^ and sebaceous 
glands. 

The old way of preparing it was as a solution in 
oleic acid (five or ten per cent.), and acetic ether 
was generally added in the proportion of one part 
to seven of the oleate. This preparation is not a 
pure oleate, and certainly is prone to decompose 
into oleic acid and metallic mercury, which de- 
posits at the bottom of the bottle. 

In 1882, I advised pure oleate of mercury to be 
dissolved in heavy petroleum oil ; giving my rea- 
son for giving up the old oleate, as follows : — 

^'The chief drawback to its use is the constant 
formation of yellow crusts on the diseased patches, 
and even on the non-infected portions of the 
scalp. These scabs have to be continually picked 
and scaled off: and,, though they often bring away 



BY THE OLBATES OF MERCUEY AND COPPER. 141 

inany diseased stumps with them^ yet it is a con- 
stant annoyance both to patient and nurse. 
Chiefly to obviate this^ and also because I think 
it is a more valuable preparation^ I have for some 
months been using oleate of mercury, dissolved in 
a heavy petroleum oil, instead of in oleic acid ; 
and, from the results I have seen, feel fully justi- 
fied in recommending this stable and convenient 
preparation as the most efficaceous parasiticide I 
know of for chronic ringworm ; it is made by dis- 
solving ten parts of oleate of mercury in ninety 
parts of heavy petroleum oil. This appears also 
to be less liable to decomposition than the or- 
dinary oleate dissolved in oleic acid. I have, 
besides, found that this preparation causes much 
less irritation of the scalp, and that children even 
under seven years of age can bear the ten per 
cent, solution well.^'* 

Oleate of mercury is now made by a process of 
double decomposition from sodium oleate, in a 
purer form than ever, according to the formula 
of Dr. Wolff, and of Dr. Shoemaker of Philadel- 
phia.t 

* Therapeutic Memoranda, by Alder Smith, Brii, Med. 
Jour., Oct. 7th, 1882. 

t " Oleates : further investigations into their nature and 
action " : a paper read by Dr. Shoemaker, before the British 
Medical Association, vide Brit. Med. Jour., Oct. 18th, 1884. 



142 CHBONIO BINQWOBM : ITS TREATMENT 

This pure oleate of mercary (mercnric oleate) 
should be dissolved in melted lard^ which is a bet- 
ter vehicle than petroleum oil : — 

^ Hydrarg. Oleat., • • Jss. ad |j. 
(Dr. Shoemaker's)* 
Adip. Benz., . . ad J v. M. Ft. Ung. 

(Melt the lard at a low temperature in a water 
bath^ then the oleate is to be well incorporated, 
without the application of further heat). 

Under no circumstances should this ointment 
be prepared by simply rubbing the ingredients 
together ; and it must not be heated sufficiently 
to cause the oleate to decompose, and metallic 
mercury to be deposited, which would render the 
preparation useless. 

This makes a ten or twenty per cent, ointment. 
If used all over the head, the former can be 
employed at first, but if only to a few places the 
latter. 

Treatment — ^The head having been prepared, as 
described on page 105, and thoroughly dried, if the 
case is an extensive one, the ointment should 

* Care must be taken that this oleate has been prepared 
by a good chemist, as described by Dr. Shoemaker. It can 
be obtained from Messrs. Corbvn and Co., 300 Holbom. If 
desired, Otto de Rose, or essential oil of almonds, may be 
added, (gt. x.) 



Bt OLEATB OF MEBCURT. 143 

be gently, but thoroughly rubbed, dabbed, and 
pressed into the entire scalp, for fifteen to 
thirty minutes with the finger protected by an 
india-rubber finger-stall, or a small sponge mop. 
This should be done regularly night and morning, 
especially into the patches. Even if there are only 
a few places, it is advisable to use the oleate all 
over the head once a day for the first few weeks, 
as it is impossible to tell exactly where unde- 
veloped points of disease exist ; but after a month, 
if there are only a few places, it can be rubbed in- 
to them twice a day, and all over the head only 
about twice a week. 

There is no occasion to leave any excess of the 
ointment on the surface of the head, as the por- 
tion that cures the disease must be rubbed into 
the hair-follicles. 

The caps (described further on) should be worn at 
night, special precaution being taken that the 
oleate does not run on to the face or pillow-case, 
as it may produce irritation, and even a rash. 

The old-fashioned preparation in oleic acid 
forms yellow crusts over the ringworm spots, 
which are very troublesome, and have to be re- 
moved with the point of a pair of forceps, or other 
means. It also causes tenderness and irritation at 
firsts especially if the child has a delicate skin, but 



144 CHBONic bingwobm: its treatment 

all these disadvantages are now avoided hj using 
the above ointment. 

If irritation be caused by the twenty per cent, 
ointment^ a weaker one can be substitated for a 
time^ and the strength increased when the scalp 
will bear it. 

During the first part of the treatment, the hair on 
the diseased patches^ or over the entire top of the 
head^ if many exists should be kept closely cut. 
This clipping should be continued about twice a 
week^ for at least three months, or until most of 
the diseased stumps have come out, and new 
downy hair is growing. 

If there are only a few patches, and the hair has 
not been entirely cut off, it is advisable to keep it 
(where it has not been clipped on the patches), 
about half an inch long. 

It is most important that the head should not be 
washed too often. If water be used, it tends to 
prevent the oleate from soaking to the bottom of 
the hair-follicles, which it is so essential that it 
should do in order to obtain a successful result. 

Therefore, while the case is under treatment, 
which may be from two to five months, let the 
head be well washed about once a month only ; 
or even not at all, as it is easy to remove any 
scales or crusts with spirits of wine, as recom- 
mended by Dr. Shoemaker. 



BY OLEATE OF MEfiCaKY. 145 

With the old preparation^ the head has to be 
washed more frequently^ as thick scales and crusts 
form in two or three weeks^ which have to be 
thoroughly removed. 

If there are any small distinct patches with 
diseased stumps^ epilation can be practised with a 
broad pointed pair of forceps^ but it is not neces- 
sary {Vide Epilation). 

It is extremely rare that oleate of mercury causes 
any iU effects any more than citrine ointment, or 
other preparations of mercury; and although I 
have employed it most extensively for very many 
years, I have only once seen slight salivation 
caused by its* use, and that was in a child four 
years of age. Pure mercuric oleate — Dr. Shoe- 
maker remarks — "is slow to give rise to sys- 
temic effect. Large quantities can be applied over 
the general surface, either in children or adults, 
with great impunity.*' 

Parents are generally frightened by the English 
name " oleate of mercury,** and imagine the gen- 
eral health of the child is sure to suffer if any 
preparation of mercury be employed. I certainly 
have seen a few children, who have appeared to 
suffer in general health from the use of the old 

* Tliis was the preparation of oleate of mercury in oleic 
acid. 

V 

L 



146 CHBOKIC UXOWOSM : US TRSATMSNT 

prepantion; bat this was quite the exception^ 
and, as a mle, it does no appreciable barm. Of 
course the case must be watched from time to 
time, and care taken that no mercnrial symptoms 
appear. 

After from three to five months of this treat- 
ment, a complete core is often effected ; or at any 
rate the disease will generally be found to be very 
much better; and to be restricted to the original 
patch or patches, or to a few disseminated stamps. 
If not, boradc acid lotion, or oleate of copper 
shonld be tried. 

If only a few diseased stamps are left, they can 
easily be removed by the treatment described 
under '' disseminated ringworm,'' Chapter X. 

If the case is not cored by oleate, bat only 
reduced to a few, small, isolated, inveterate 
patches ; the stage of tlie treatment is reached at 
which I so strongly recommend what I have called 
"the artificial production of herion" — i.e., that 
swollen, raised, inflamed, and infiltrated state of 
the scalp, which sometimes occurs accidentally 
daring treatment, and which then always restdts in 
a speedy cure of the disease* 

Oleate of copper ointment.— Oleate of copper 
has also been made in a pure state by the process 
mentioned by Dr. Shoemaker.* 

• Fide foot note, p. 141. 



BY OLKATB OF COPPER. 147 

The nse of this prepai*ation for all forms of 
ringworm^ has lately been strongly advocated by 
many medical men^ as mentioned on page 122 ; — 

Jj^ Cupri Oleat., . . . 3 v. ad 3 x% 
(Dr. Shoemaker's)* 

Otto EossB Virg., . . gt. x. 

Adip. Benz., . . . ad J v. M. Ft. Ung. 

(Melt the lard by the help of a water bath^ and 
stir in the oleate until completely dissolved.) 

The strength may vary from one to four 
drachms to the ounce^ according to the nature of 
the case^ but one and a half drachms is usually 
strong enough. 

It should be used in the same way as oleate of 
mercury ointment; and during trJtment, wash- 
ing should be avoided as far as possible^ and if 
the head requires cleansing^ it can be done best 
by spirits of wine. One of the chief advantages 
of using oleate of copper^ is that epilation is not 
necessary^ but stilly if the places are small in ex- 
tent^ it can do no harm^ and possibly much good 
by breaking off the stamps some little way into 
the follicles. 

The only objection to the use of this prepara- 
tion is its brilliant green colour ; but as the good 

* Fide foot note p. 142. 

l2 



148 CHRONIC binqwobm: its treatment. 

done by it depends upon the amoant forced into 
the hair-foUicleSj the excess^ after it has been well 
rubbed in^ may be wiped off. 

At times it produces irritation of the scalp^ and 
then the ointment must be diluted by adding 
more lard^ until the skin will bear it : but I have 
seen, it cause so much irritation^ with pustules and 
crusts^ that it had to be entirely discontinued. 
In such cases I have found that oleate of mer- 
cury could be borne very much better than oleate 
of copper. Now and then blind boils form^ and 
are very troublesome^ but they rarely do any 
harm ; and^ as a rule^ while the treatment is con- 
tinued^ they subside. In such cases general 
treatment does good^ and sulphide of calcium 
pills can be given^ together with tonics. 

Latterly I have used oleate of copper very ex- 
tensively^ and must say that I am very pleased 
with the results I have obtained ; and think it is 
quite possible it may supersede the use of oleate 
of mercury, and most other parasiticides ; yet it 
occasionally fails to cure chronic ringworm, even 
after it has been rubbed in for many months. 



obnbbal directions. 149 

Genejbal Dibections During Treatment. 

Hair Cutting.* 

Dnring treatment^ the hair should be kept very 
closely cut on the patches ; and the rest of the 
hair^ if it has not been removed and the patient 
is a boy, should be worn about half an inch to 
one inch long. But it is advisable to let the hair 
grow for a week on the places before the case is 
examined by the doctor, to see how it is pro- 
gressing ; for, if the hair be newly cut, it is im- 
possible to see the number of stumps. 

Gaps. 

Day-Caps. — If there are only a few places, it is 
not necessary for a cap to be worn during the day; 
but if the disease be at all extensive and the hair 
has been removed, or if an ointment be used, it is 
generally advisable to order a cricket, polo, or 
black silk cap. 

Night-Caps. — In using an ointment, carbolic 
glycerine, Goa powder, and irritating remedies, it 
is necessary to exercise great care to prevent the 
preparation from getting on to the forehead or 
face during the night-time. 

• TtWtf page 105. 



150 aSNKBAL DIBICnONS: CAPS. 

Therefore^ the chief nse of night-caps is to pre- 
vent the pillow-case getting soiled with the remedy, 
and thus causing irritation of the face by the child 
lying on it. 

The best way to avoid this is to nse a double 
cotton cap as a night-cap^ having the back part 
gathered^ and tapes attached both before and be- 
hind the ears^ so that they will tie underneath the 
chin. It is also often necessary to fix it in posi- 
tion by putting one or two turns of a bandage 
round the head like a turban. This will fix the 
cap at its edge^ and prevent it from slipping dar- 
ing sleep. I formerly advised an oil-silk cap to 
be worn outside the cotton one^ when ointment or 
oleate of mercury was used^ but it is not necessary 
to leave much ointment on the surface of the scalp; 
for it is evident that the good results obtained from 
these remedies depend entirely on the amount 
which is rubbed into the follicles^ and not upon 
what is left smeared on the surface of the scalp. 
Therefore^ almost all the ointment used should be 
rubbed in^ or removed ; and should not be left on 
the head so that it can saturate the night-cap. 

If it is found necessary to use something to 
prevent the ointment passing through the cap on 
to the pillow case^ the best plan is to place a piece 
of gutta-percha tissue over the white cotton cap, 



APPLICATION OF BEMEDIES. 151 

and to fix it in position with one or two turns of a 
bandage^ as before described. 

Special precautions must be taken when Goa 
powder^ or chrysophanic acid ointment is used^ or 
else a child is almost certain to make its cap slip 
during the nighty and thus get the irritating and 
staining parasiticide on to its face. Sometimes 
the edge of the cap^ when using oleate or oint- 
ments, will get saturated with the remedy, and 
cause much irritation upon the more delicate skin 
of the forehead. 

If boracic acid lotion is employed, it is sufficient 
to use a simple white cotton cap. 

The caps should be changed every two or three 
days, and the soiled ones washed. Some prefer 
to use a large cotton handkerchief, which should 
be folded in a triangular shape, and the long side 
should be placed over the forehead so that the 
handkerchief covers the head, with the right- 
angled corner behind; then the two other ends 
can be tied round the back of the head to make it 
into a cap. 

Application of Bbmbdies. 

Ointments and lotions, as a rule, are not pro- 
perly applied, nor is sufficient time spent by the 
attendant on the care of the case. They are gen- 



152 FBEVEKTION OF SPBIADING. 

erally simply rubbed on to the places, instead of 
being ihorougUy rubbed into the hair-follicles. 

It shoald always be remembered that the fan- 
gas is rapidly insinuating itself into the deeper 
parts of the follicles^ and that to secure success in 
treatment^ much time must be spent in the proper 
application of remedies. The parasiticide^ whether 
in the form of lotion or ointment^ ought to be well 
rubbed^ dabbed^ and pressed into the hair-follicles 
for ten to thirty minutes^ at least twice a day. 

Peevkntion of' Spbbading. 

During the treatment of the diseased places, 
the rest of the head must not be forgotten. For 
it often happens that ringworm exists on other 
parts of the scalp^ but in a state not recognisable 
by the eye. 

Therefore^ it is most important not to devote all 
the attention and treatment to the places dis- 
tinctly seen — for while these are being cured, if 
proper precautions are not taken^ other small spots^ 
where the disease has been overlooked in its in- 
cipient stage, make their appearance, and the 
medical attendant may find when he has cured the 
first patches, that he has several more to deal 
with — but the whole scalp should be examined now 
and then during treatment ; and some parasiticide 



WASHING. 153 

used all over the head, even when only a single 
patch of ringworm exists. 



Washing. 

Some advise constant washing of the head 
daring treatment^ while others discard its use 
altogether^ and believe that it helps to spread the 
disease by carrying the spores over the head. I 
certainly do not believe it spreads ringworm, if 
proper parasiticides are employed ; but it entirely 
depends upon the nature of the treatment, 
whether frequent washing be required or not. 

If chrysophanic acid in chloroform, or spirit 
lotions be used, it is advisable to wash the places 
every day to get rid of all scurf and sebaceous 
matter ; but if oleatea are employed, it is worse 
than useless to wash more than every three or 
four weeks. It is well to wash the head once or 
twice a week, when ordinary ointments are used, 
carbolic glycerine, Goa powder, sulphurous acid, 
acetic acid, etc.; but this has generally been noted 
under the special treatments. The whole head 
should always be thoroughly cleansed, and then 
well dried, before any lotions or ointments are 
first rubbed in. 



154 crusts and scabs. 

Cbusts and Scabs. 

It is not advisable to cause any crnsts or scabs 
over the patches of ringworm ; and if this com- 
plication occur^ it is nseless to continue the appli- 
cation of any parasiticide to their outer surfaces^ as 
it will not penetrate^ and the fungus may continue 
to grow rapidly beneath them. It is better, there- 
fore, to pick off all scabs with forceps as soon as 
they form, and to epilate — removing all the dis- 
eased hairs, as far as possible, before applying the 
remedy again. If there is any difficulty in remov- 
ing crusts, they should be soaked and softened 
with oil, and poulticed at night, when they will 
easily be removable the following morning, on 
bathing them with hot water. 

Epilation. 

Epilation is strongly recommended by many as 
a most valuable help in treating ringworm, but 
fortunately it is not a necessity with the new 
treatments, although perhaps advisable if the 
places are small in extent. The objections to its 
use are the time it takes, and the pain it causes. 
Many medical men say it is quite useless, as the 
hairs break off near the mouths of the follicles; 



EPILATION. 155 

bat it must be remembered that the diseased 
hairs plag the orifices of the follicles^ and if we 
can remove only a small portion of the stamps, 
we enable the ointment to be rubbed in better. 

If the places are at all extensive I rarely advise 
epilation, as the time spent apon it can be much 
more profitably spent in rubbing in the remedy ; 
but if there are only a few places, and the child can 
bear it, I do, as it probably hastens the cure, es- 
pecially if the stamps are at all loose, and can be 
extracted entire. The first time I see a small recent 
patch, I always epilate at once, for then many of 
the diseased hairs can be removed. With exten- 
sive ringworm — under boracic acid or oleate of 
copper— it is rarely worth the time and trouble. 
It is also useless if the hairs are very rotten, so 
that they break off on a level with the surface of 
the skin, which is often the case in chronic ring- 
worm. 

Epilation should be done with a broad-pointed 
pair of forceps ; some advise broad and straight 
points, others broad and curved. It is best to 
pull the stumps gently, with a steady motion, and 
in the same direction in which they protrude. 
They must not be jerked out. The forceps can be 
cleansed each time, by wiping them on a small 
sponge placed ready for the purpose in a small 
basin of water. 



156 PBIVXMTIVE LOnONS AND OINTMINTS. 

Epilation, if done at all, most be resorted to 
OTor and over again, as long as any diseased hairs 
appear. 

PRKYEirnYi Lotions and Ointments. 

When boracic acid lotion, oleates, ointments, 
&c., are nsed, if there are only a few patches, and 
the hair has not been entirely removed, it is of 
the utmost importance to rub the lotion or oint- 
ment into the roots of the hairs all oyer the head, 
once a day during the first few weeks of the treat- 
ment, to insure the destruction of any conidia that 
may be about. If this is not done, the disease 
may spread, or more likely still, minute places 
just commencing, which have been oyerlooked at 
the first examination, will develop ; but if a para- 
siticide is used all over the head, this will be pre- 
vented, and the patches of incipient disease will 
soon be cured. 

If strong remedies be used to the patches, some 
preventive must be used all over the head, if we 
wish to stop the disease from spreading. 

The following lotions or ointments may be em- 
ployed for this purpose : — 

A solution of chlorinated soda, diluted with 
seven parts of water — a saturated solution of 
boracic acid in spirits of wine — hyposulphite of 



PERIOD OF TREATMENT. 157 

soda lotion (one to two drachms to the ounce 
of water) — carbolic glycerine (one part to six or 
seven of glycerine) — bichloride of mercury lotion 
or ointment (one grain to the ounce) — sulphurous 
add lotion (two drachms to the ounce) — salicylic 
acid lotion or ointment (ten to thirty grains to 
the ounce) — boro-glyceride and glycerine (one to 
two parts)— or the following ointment : — 

Jt Hydrarg. Ammon.,* . . gr. xl. 

Hydrarg. Ox. Bub.,* . . gr.xx. 
01. Amygd. Essent., vel 

Otto Bos8B Virg., . . . gt. viij. 

Adip. Benzoat., . . . . | iv. 
M. Ft. Ung. 

* To be finely levigated. 

Sig, — The preventive ointment. 

Note. — I take this opportunity of mentioning 
that vaseline is 7iot a good vehicle for parasiticides^ 
as it does not penetrate far into the hair-follicles^ 
nor is petroleum oil as good as spirits of wine^ 
ether^ chloroform^ or turpentine. 

Period of Treatment. 

It generally takes three or four months at the 
least to cure ringworm ; and very often^ especially 



158 THK GBNEBAL HEALTH. 

if the disease has existed some time before it 
comes under efficient treatment^ it may take many 
months, or even a year. 

Recent small places can often be stamped out 
in a month or two, but no definite time can be 
given, as sometimes slight cases resist all treat- 
ment for months and months, and at other times 
even chronic ringworm can be rapidly cured. 

Thi Genebal Health. 

It is advisable, if the disease is at all extensive^ 
and the patient is weakly, strumous, or of the 
lymphatic temperament, to see to the general 
health. Iron may be given, with cod liver oil, 
etc., as advised in Cuapter XI. 

Indications showing that a Eemedt is Operatinq 

Beneficially. 

It is very difficult to judge of the true value of 
any remedy for a case of ringworm, unless it be 
kept under observation for some time after it is 
supposed to be cured. 

No reliance can be placed on statistics drawn 
from out-patient rooms, as mothers will not bring 
their children back for treatment, when the dis- 



SIGNS OF IHPBOVEMXNT. 159 

ease appears to them to be well. Thus many 
cases are thonght to be cured^ when the disease is 
simply in a chronic condition. 

When a remedy is operating beneficially the 
places cease to spread^ no fresh patches of ring- 
worm occur^ and if the stumps be examined^ 
they will be foond to have less fungus upon them^ 
some of the hairs become less brittle^ and often 
many of the stumps come out when tried with the 
forceps. This is a very good sign if boracic acid 
is being used^ also if the places become smooth 
and shining^ like alopecia. A bald place may 
continue for a little while^ but the new downy 
hair soon commences to replace the stumps which 
have fallen out. Microscopical examination will 
also be of help in deciding how the case is pro- 
gressing. 

Thb Body. — During the treatment of ringworm 
of the head^ especially at first, the body should be 
examined for any small patches of tinea circinata. 



160 CHRONIC BINGWOBM: ITS TBEATMEKT. 



CHAPTER IX. 

The Artificial Pboduction of Kebion. 

THB TREATMBNT OF CHBONIC BINOWOBM, WHERB THE 
DISEABB DOBS NOT BXTBND OYBB A LABGB BXTBNT 
OF 8URFACB : AND THB TBEATMBUT OF TINBA BBRI05. 

Kebion is a variety of the disease that sometimes 
occars accidentally during treatment^ or that may 
arise spontaneously. The patches become tender, 
raised^ swollen, red^ and infiltrated. If this hap- 
pen, it is, in my opinion^ a most fortunate occur- 
rence^ as it is Nature's method of efiecting a cure. 
Observing this, I have constantly for more than 
eleven years, been in the habit of using croton oil 
or the artificial production of this variety of the 
disease, and can most positively assert, that in 
imitating this curative action of nature, we have a 
most valuable means at our disposal for eradicating 
small patches of inveterate ringworm, even when 
all other treatment has failed. 

By applying minute drops of croton oil to indi- 
vidual diseased hairs, we employ the best means I 
am aware of^ for rapidly removing the isolated 



THE ARTIFICIAL PEODUCTION OP KEBION. 161 

stumps^ and black dots^ which exist in dissemi- 
nated ringworm; and also for loosening the 
stumps on a large chronic patch, which may 
have existed for years, and which has been thought 
to be scurf or eczema. 

Kerion should be produced, if possible, in small 
inveterate patches of chronic ringworm, which have 
resisted all other treatment for months or even years, 
and NOT in those cases where the disease extends 
over a large extent of surface, nor in recent ring- 
worm. Croton oil is the best irritant for causing 
this inflammatory condition ; but it must be used 
with great caution, and at first only applied to a 
small place, and its effect watched. I generally 
put it on a patch about the size of a sixpence, 
with a small cameFs hair brush, and order a 
poultice to be applied at night, and firmly tied on 
so that it cannot slip. Then, if the oil has not set 
up severe inflammation and pustulation by the 
next day, which is very rare, I apply it again, 
keeping poultices constantly on day and night. A 
pustular rash occurs at once, but the oil can be 
applied over this, after all the crusts have been 
removed by bathing ; and a daily application of it 
for three, six, or more days, together with con- 
stant bathing with hot water, and frequent 
poulticing with linseed-meal, will often set up such 

H 



162 CHBONic bingwosh: its tbsathbnt. 

inflammatory exudation^ that the patch resembles 
true kerion. 

It may thus become very tender, swollen, puffy, 
pustular, and even at times boggy to the touch. 
It is generally covered with a thick yellow incrus- 
tation : on removing this purulent substance with 
the point of the forceps, and a sponge and warm 
water, the skin underneath will be found to be 
very red and tender, with sometimes a muciform 
or purulent discharge, exuding from the follicles ; 
and, what is more important, the hairs and stumps 
loosened. These either come away with the dis- 
charge, or can be easily pulled out. If the patch 
is very much swollen, the hairs on being extracted 
come out from a considerable depth. 

When the patch is inflamed and infiltrated, so 
that the stumps come out easily, soothing reme- 
dies, such as poultices with olive oil, or water- 
dressing, and bathing should be continued for 
some days; and then, when the tenderness has 
abated, and all the yellow incrustation has been 
removed by bathing, the stumps that are lefb on 
the patch should be pulled out, using for this pur- 
pose a broad-pointed pair of forceps. 

Water-dressing or vaseline should then be 
applied till all the inflammation has subsided, 
while the remaining stumps are removed from 
time to time. 



THE ARTIFICIAL PRODUCTION OF KERION. 163 

It is advisable to see a case when in this condi- 
tion, every three to seven days, and to carefully 
examine the spot with a lens to discover any 
stumps which may need extraction. 

If after a few applications of the oil, there i^ no 
appearance of kerion, but only irritation and 
severe inflammation, very great care must be exer- 
cised to prevent any superficial sloughing of the 
npper surface of the skin. The oil should only be 
used every other day instead of every day, and a 
very small quantity employed. As long as the 
skin is only red underneath the yellow matter or 
crusts, all is going on well, but if it appear to 
have a white skin adhering to it, — that is a slight 
slough — the oil must at once be discontinued and 
soothing applications only employed, or else a bald 
spot may be caused. 

The great aim of this treatment is to cause inflam- 
matory swelling and effusion into the tissues around 
the follicles y so that the stumps, which otherwise 
would break off on attempted epilation, are 
loosened by the exudation, and will now come 
out with the discharge, or can easily be extracted. 
In fact, in a very short time, an inveterate patch 
of ringworm, which has withstood every other 
treatment for years, can be often transformed into 
a smooth, shining, slightly raised red surface, 

m2 



164 CHRONIC bingworm: its treatment. 

utterly destitute of all hair and stumps^ and 
practically well. 

If the patch happens to be a large one, with 
isolated stumps scattered all over it among the 
healthy hairs, it is advisable to apply the oil only 
where the stumps exist, and to extract them, 
leaving the long hairs. Thus a large temporary 
bald spot is avoided ; but still, if much inflamma- 
tion and exudation have been produced, the long 
hairs will fall out as well. Large scurfy places 
with isolated stumps can almost always be cured 
without producing kerion, by following out the 
treatment described in the next chapter. 

If there is more than one patch, the oil should 
soon be applied to the second or third, when it is 
seen that the first one is progressing favourably ; 
and thus we should try to get every place con- 
verted into a condition resembling kerion. The 
largest patch I have inflamed at one time has been 
about the size of a five-shilling piece; but I 
should never attempt such a large one at first, and 
would prefer to treat a half or a third of it, and 
then the rest afterwards. 

Especial care should be taken not to apply too 
much croton oil at a time, and to see that the 
poultice is firmly fastened on to the spot ; other- 
wise the oil may run on to other parts of the head 



THE ARTIFICIAL PRODUCTION OF KERION, 165 

or forehead; or, by the poultice slippiDg, kerion 
may be produced where it is not wanted. If the 
oil by any means get on the pillow-case, and the 
child rub its face on it, of course a pustular erup- 
tion will follow. I have seen cases where, through 
carelessness, the oil has been allowed to get on to 
the pillow-case, and then during the night has 
been rubbed on to the forehead and cheeks. If 
this accident happen, an universal crop of minute 
pustules will probably occur on the face. When I 
first saw a case of this kind, it gave me great 
anxiety, lest some marking should ensue; but 
with soothing applications and simple ointment, 
the slight crusts were speedily removed, and not 
the least mark remained. Of course, with proper 
precaution, this accident should never occur. 

While the croton oil treatment is being con- 
tinned, oleate of mercury, carbolic glycerine (one 
to five or seven), or some other parasiticide, 
should still be applied to the scalp, and even 
placed on the sore places, or on the poultice. 

When once a stump has been extracted with 
the entire bulb, there is no fear of the new hair 
becoming infected with the fungus, as some of the 
parasiticide used is sure to get into the hair- fol- 
licle, and destroy any conidia left there. 

When the stumps have been removed, a sim- 



166 CHRONIC kingworm: its treatment. 

pie ointment can be used ; and when the swelling 
has subsided^ and only a bald place remains — all 
traces of inflammation having passed away — the 
following hair-wash can be employed to promote 
the growth of the new downy hair : — 

Jt Tinct. Cantharid., J j. ad |iss. 

Acid. Acetic, . . . . J j. 

Glycerin., 3 iv- 

Sp. Eosmarin., . , . Jj. 

Aq. Eosaa, ad ... J viii. M. Ft. Lot. 

SIg. To be rubbed into the bald places, night 
and morning. 

— or tincture of iodine can be painted every day 
or two on the bald places. 

The bare patches that remain after this treat- 
ment may continue for a month or two ; but the 
hair will grow again sooner or later, if only kerion 
has been produced. 

Sometimes when one or more patches have been 
treated in this way, in the course of time other 
small places or isolated stumps may re-appear 
here and there ; therefore, the whole scalp should 
be examined week after week, and any stumps 
removed or touched with croton oil, as described 
further on under " the treatment of disseminated 
ringworm.'^ But even when the case has been 
pronounced absolutely well, one or two isolated 



THE ARTIFICIAL PEODUCTION OF KERION. 167 

stumps will often re- appear, time after time; 
hence children ought to be examined once a month, 
for two or three times, after the disease appears 
to be eradicated. 

Some remedies may produce kerion unexpect- 
edly. I have seen carbolic glycerine, citrine oint- 
ment, and oleate of mercury act in this manner. 

If this puffy state occur accidenlally during 
treatment, simple poulticing and bathing, as be- 
fore described, must at once be adopted ; all the 
hairs should be carefully extracted when loose; 
and diluted boro-glyceride can be used; and, after 
a time, a stimulating hair- wash employed. 

The parents are, as a rule, greatly frightened 
when kerion is produced ; so that it is better to 
explain to them beforehand the reasons for adopt- 
ing this treatment, and the result to be expected 
from it. The condition is somewhat painful, and 
much resembles that caused by the formation of 
an abscess ; the glands also often enlarge about 
the back of the neck, but I have never seen them 
suppurate ;* and the swelling soon subsides after 
the local irritant is discontinued. 



* Since the above was written, I have seen one case 
where an abscess formed, but it caused no permanent mis- 
chief. 



168 CHRONIC BINOWOBM: ITS TREATMENT. 

Sometimes kerion is rapidly set up ; at otter 
times it is most difficalt to induce. Croton oil 
may sometimes be applied over and over again^ 
eyen for weeks^ without causing the swollen^ pn% 
state of the scalp desired ; but^ even if the infil- 
trated condition of the skin cannot be produced^ 
and a deep pustular rash alone is formed^ more or 
less inflammation and exudation is always set up^ 
and the treatment very rarely fails in loosening 
the stumps and curing the disease. Again^ if the 
stumps are only partially removed by this treat- 
ment^ it enables the oleate to penetrate into the 
lower portions of the follicles^ and thus to destroy 
the conidia existing there. 

If only a pustular rash has been produced^ and 
not kerion, it generally happens that many of the 
stumps break on attempted epilatiou. If this 
occur^ it is better immediately to place a minute 
drop of croton oil on, or into the follicle, by the 
aid of a veiy fine brush, or the point of a gold pin. 
This will probably cause the expulsion of the 
stump in a few days. At the next examination 
the same plan should be followed, and so on, until 
it is impossible to find a single stump, even after 
watchiug for a month {Vide Chapter X,). 

In some rare cases, where the scalp will not 
puflF up and become infiltrated, but only inflame^ 



THE ARTIFICIAL PEODUCTION OF KERION, 169 

and when croton oil has been employed many 
times, I have seen a superficial slough occur, 
and the hair has not thoroughly grown again. 
This very rarely happens, and never in my ex- 
perience, if the oil has only been applied a few 
times; and, as I only advise this extra severe 
treatment in very exceptional cases, and on very 
small placesy I consider that it is better for a child 
to suffer the loss of a slight quantity of hair on a 
small place, than — by being prevented attending 
school — to lose its education. Even if some of 
the hair-follicles be destroyed by this treatment, 
the majority of the hairs will still grow on the 
place, and a distinct bald patch ought never to be 
left. In fact, a scar equal to that caused by a 
cut head, is but rarely made. 

Croton oil should of course be applied only by 
or under the eye of the medical attendant ; and I 
may mention, lastly, that I have never seen any 
internal irritation or erysipelas occur from its use. 

As much discussion has occurred in the Medical 
Journals since the publication of the greater part 
of the above remarks on kerion,* I must call 
special attention to the fact, that it is not a subcu- 
taneous or other abscess. I do not advise such 
severe treatment as that. 

• The Lancet, Jan. Slat, 1880. 



170 CHBONIC BINOWORM : ITS TREATMENT. 

" Kerion/' according to Dr. Tilbury Fox,* " has 
much the appearance of a threatening abscess, 
mth loss of hair. The disease is made up of a 
patch or patches, which are circular, swollen, and 
so much raised and changed as to resemble a 
threatening boggy abscess. Each patch is more 
or less red, tender, feels semi-fluctuant and soft^ 
and in the earUer stage is studded over with little 
openings, which are the mouths of the hair 
follicles, and from each of which a muciform dis- 
charge like the juice of the mistletoe-berry exudes. 
Some of the hairs are lost, but many others 
emerge from these orifices, and can be readily 
pulled away, and, in fact, they are lying loose in 
the follicle; others lie loose about the patch. 
After the early stage, the hair falls of its own 
accord, and a swollen, red> inflamed, exuding 
patch is left. If the hairs are examined, they 
will be found to be surrounded and loaded with 
fungus. The disease is modified by the inflamma- 
tion of each follicle, and the inflammation detaches 
the hair from its root-sheath, so that it lies loose 
in the follicle.'^ 

This is true kerion — a variety of the disease 
that) may occur idiopathically, or under any treat- 

♦ Ringworm and its Management^ Dr. Tilbury Fox. 



THE ARTIFICIAL PRODUCTION OP KERION. 171 

ment — the attempted artificial production of which 
I specially advise in suitable cases. 

A deep pustular rash is easily formed by croton 
oil^ but that alone is not the essential part of my 
treatment; which consists in the actual infiltration 
of the true shin with inflammatory products, causing 
the stumps to become loosened. If this state can 
be produced^ the case is practically cured, and tho 
further use of parasiticides is hardly necessary, as 
the inflammatory effusion destroys the fungus. 

I should be sorry for the profession to think 
that I advocate the production of kerion indis- 
criminately in chronic ringworm, especially where 
a large extent of surface is involved. In fact, the 
chief cases for which I urge it are those I so con- 
stantly see, where, after ordinary treatment for a 
time, the hair has grown again on the patches, 
and the child has then been neglected for months 
or even years, until some special reason brings it 
under treatment again. 

Ordinary chronic forms of ringworm can gene- 
rally be cured, or considerably reduced in size, 
by boracic acid lotion, or by the oleates of mer- 
cury or copper; and the production of kerion 
should not be attempted until after a fair trial for 
some months with one or all of these parasiticides. 

Touching the individual stumps — as described 



1 72 CHRONIC BINQWORM : ITS TREATMENT. 

n the next chapter — is much safer than attempt- 
ing to produce kerion over a large surface. 

A deep pustular rash alone, involving the tissues 
to the depth of the hair- follicles, will often cure 
chronic ringworm, but certainly not all inveterate 
cases. I know full well, from painful experience, 
that if a condition resembling kerion cannot be 
produced, croton oil may be painted on time after 
time, and a pustular rash repeatedly set up, and 
yet diseased stumps will re-appear. 

It is after this treatment — whe7i kerion has not 
been set up — that I have often noticed some of the 
follicles have become obliterated, and thus no new 
hairs have replaced the diseased stumps. There- 
fore, when the case is cured, the patch is gener- 
ally recognisable by the hair being scanty on the 
spot, but no distinct bald place ought to be made. 

If a chronic patch of ringworm be left alone, 
after one or two applications of croton oil, followed 
by a pustular rash and yellow incrustation, hut 
without the infiltration of the shin, all may seem 
well, and the disease may appear to be cured, yet 
the stumps will almost certainly crop up again 
and again. I speak very strongly on this point, as 
medical men so constantly make a mistake in 
thinking a patch cured, because it appears free 
from stumps. In ordinary private and hospital 



THE MOST SUITABLE CASES FOB KEBION. 173 

practice^ patients are oflen not seen again when 
they have once been considered well ; and yet, if 
they were examined after two or four weeks (as 
boys are, after having had ringworm, in a large 
school), the diseased stnmps would constantly be 
found to have re-appeared. 

Such cases are very difficult to cure ; and the 
only way to remove the stumps is to place the oil 
into the hair- follicles with a gold needle, or to 
try electrolysis. 

At first I employed the liniment of croton oil, 
but gave it up nine years ago for the pure oil, as 
the alcoholic solution is more apt to run beyond 
the limits of the spot painted with it, and thus 
cause pustulation where it is not wanted. This is 
especially seen when applying the oil to isolated 
stumps. 

THE FOLLOWING IN MY EXPERIENCE, ABE THE 
MOST SUITABLE CASES IN WHICH THE PBODUCTION OF 
KEBION MAY BE ATTEMPTED. 

1. Inveterate patches of ringworm, if not very 
extensive, and which have resisted all other treat- 
ment for months or years ; especially those where 
the inveterate parts of the patches have been 
marked out and reduced in size, by other treat- 
ment, as by oleate of mercury. 

2. Any small patch of ringworm (not a recent 



174 CHRONIC BINGV70BH: ITS TREATMENT. 

or spreading case), not larger^ say^ than half-a- 
crown, where time is of the utmost importance, 
and a care is desired as quickly as possible. 

3. In cases, for example, where ringworm has 
been detected and properly treated for a time, 
imtil some new hair has made its appearance; 
after which, treatment has been discontinued, al- 
though many diseased stumps remained. Months, 
or even years have passed, and the child is per- 
haps rejected at some examination, for admission 
into a school. One or more patches are to be 
seen where the hair is growing freely and firmly, 
but on close inspection with a lens, some scurfi- 
ness and many broken hairs or stumps are to be 
observed^ scattered among, and concealed by the 
long hairs on the patches. In such cases, if ex- 
tensive, the stumps should be loosened by croton 
oil, and removed singly by the fine forceps, with- 
out extracting the healthy long hairs. 

4. Pustulation, in minute spots, should also be 
attempted, as probably the only cure (except by 
electrolysis) for that variety of the disease called 
disseminated ringworm. 

Note. — Croton oil should not be used to child- 
ren under six or seven years of age, unless under 
very exceptional circumstances. 

In conclusion, I would warn medical men never 



DANGERS OP USING CfiOTON OIL. 175 

to apply croton oil to a recent and spreading case 
of ringworm, nor to employ it to ordinary cases of 
chronic ringworm, without due consideration. If 
this be done, the medical practitioner will be sore 
to get into trouble sooner or later. The oil often 
causes much inflammation; the parents get fright- 
ened, and imagine the doctor has made the disease 
ten times worse. They may seek other advice, 
and be told that their former medical attendant 
has been greatly over-treating the case, and has 
been using too strong remedies. Under soothing 
applications, the little patient gets well, and the 
second attendant gets the credit of curing the 
parasitic disease, which was practically well when 
he first saw the case. I always fully explain to 
parents beforehand the reasons for adopting this 
treatment, and the results to be expected from it. 
Again, it must always be remembered that there 
is the possibility of bald places being left after the 
application of croton oil, especially when kerion 
has not been produced. 

It is also important to bear in mind, that simple 
remedies will generally be efficacious in eradicat- 
ing ringworm in young children, and that with 
them, strong irritants should never be employed. 



176 CHRONIC BINGWORH: ITS TREATMENT. 



Treatment of Tinea Kerion. 

If kerion occur idiopathically^ as a variety of 
ringworm (described p. 170), the treatment of tlie 
case requires great care. AH irritating remedies 
should be specially avoided. The swollen patches 
should first be well bathed with hot water^ and 
then^ as many of the hairs and stumps as possible, 
should be carefully extracted. This removes a 
large proportion of the fungus, as the hairs, and 
the follicular linings, come away together. Some- 
times the hairs will be extracted from a great 
depth, due to the swelling of the part. The best 
local applications are: boro-glyceride, diluted with 
water or glycerine (one to two) ; a lotion of hypo- 
sulphite of soda (two drachms to the ounce) ; or 
of sulphurous acid and water (equal parts), the 
latter should be constantly applied on lint, under 
an oil-skin cap. At night-time, after bathing and 
again extracting any hairs that are visible, a poul- 
tice can be applied with boro-glyceride, or a little 
carbolic oil (one in twelve) on it. 

The great point in the treatment is to remove 
the diseased and loosened hairs, with the fungus. 
Then the swollen patches will rapidly subside 
under boro-glyceride, or sulphurous acid and 



TREATMENT OF TINEA KERION. 177 

water dressing. It is quite a mistake simply 
to apply poultices^ and to leave the hairs to drop 
out. When all the inflammatory swelling has sub- 
sided, the hair-wash (mentioned under the treat- 
ment of Alopecia, in Chapter XI.), or tincture of 
iodine can be employed to promote the growth 
of the new downy hair. 

I have seen some very extensive and severe 
cases of tinea kerion occur, while the simplest 
applications were being used. Some years ago 
I watched two young children — brothers — who 
had most extensive kerion almost all over their 
heads, from the use of a very simple remedy, 
'^ chrism a." Both cases commenced together, and 
in one, a subcutaneous abscess had formed before 
I saw the boy. This was at once opened ; and 
the cases were treated as advised. Almost the 
entire hair came away, so that the children were 
bald for a couple of months ; but when I saw them 
three months afterwards, there was a universal 
crop of new hair growing, except where the sub- 
cutaneous abscess had formed. A scar had formed 
there, as the follicles had been destroyed. 

A suhimtaneous abscess is a very rare complica- 
tion, and it was evidently, in this case, the result 
of a decidedly strumous diathesis. 

It will be well here to caution any one against 

N 



178 INCURABLE CASES OF BINOWOBM. 

mistaking kerion for an abscess, and opening it. 
This mistake is likely to be made, and most cer- 
tainly shoald be avoided, as it would probably be 
followed by troublesome sapparation. 

In severe and protracted cases, especially if 
they are not properly treated, the hair-follicles 
may be destroyed, and permanent baldness result. 



Incurable Gases of Extensive Binoworm. 

Unfortunately the disagreeable fact has some- 
times to be faced that chronic and extensive ring- 
worm cannot be eradicated by any of the known 
remedies 3 such cases being too extensive to at- 
tempt the artificial production of kerion by croton 
oil. I have seen children-and even now have 
such under my care — ^who have resisted the action 
of ordinary ointments, oleate of mercury, boracic 
acid, thymol, Goa powder, creasote and turpen- 
tine, oleate of copper, the water from the gas 
works (which some think is a certain cure), &c., 
and months of treatment by old women specialists, 
cobblers, and the assiduous application of well 
advertised quack nostrums (which are generally 
said to cure the disease in a few weeks) for years. 



THE TRBATMBNT OJ" DISSEMINATED EINGWORM. 179 



CHAPTER X. 

The Treatment of Disseminated Ringworm. 

In some inveterate cases — which have resisted 
the action of parasiticides — where all the patches 
have disappeared^ and the disease has passed into 
the disseminated variety (described p, 34), I be- 
lieve the best chance of a cure is to subject the 
entire scalp to a very close examination with a 
lens, and to place, by the aid of a very fine sable 
brush, a minute drop of croton oil, wherever the 
isolated stumps or the black spots can be seen. 
(A case where the black dots are observed,* is one 
of the most diflScult to cure). 

If there are only a limited number, the oil can 
be pressed into the follicles, by running the point 
of a very fine blunted gold pint into them, by the 

• Fide)}. SI. 

t The pin I use is mounted, and about the size of a fine 
sewing needle ; the end is bent, and the point blunted so 
that it will pass into the hair-follicle without causing any 

n2 



180 CHBONic bjnqworm: its tbeatmbnt, 

side of the diseased stamps. The oil usually 
causes a pustule^ and the loosened stump comes 
out with the discharge, or can afterwards be re- 
moved with a pair of forceps. 

Those made for me are slightly curved towards 
the ends, which are strong, yet fine, and have 
minutely serrated points {Vide l^^g. 2). 

A lens is also necessary — an ordinary botanical 
one does very well, Fig. 8 — and it should be held 
between the first finger and thumb of the left 
hand, while the other fingers hold away the long 
hairs from the patch it is desired to treat. 

The best way to thoroughly examine the whole 
scalp, is to follow out the directions given on 
page 24. The child should be examined close to 
a window, where there is a good light; and in 
such a position that the light falls on the right 
hand side of the examiner. 

Then commencing at the top of the back part 
of the head, layer after layer of the hair should be 
turned upwards {in the wrotig direction), with one 
blade of the forceps, while the hair just turned up 

bleeding. But I generally employ a very small morphia- 
syringe, with a fine bent needle not larger than a sewing 
needle, having the hole at the point. This is filled with 
croton oil, and is a very useful little instrument when many 
cases have to be treated. 



THE TBEATUKNTOF DISSEHINATBD BINQWOBU. 181 



■ Tliete forceps can be obtained at Metm. Arnold and 
Sons, Smithfield, E.G. 



182 CHBONic singworm: its treatment. 

is held down with the second to the fourth fingers 
of the left hand^ until the whole of the scalp has 
been examined. During the examination^ a 
minute inspection should be made with a glass, or 
simple eyesight, for any broken hairs or black 
dots, and the point of the needle — previously pre- 
pared and dipped in croton oil — should be run 
into all the diseased follicles. 

Then the child should be turned round, and the 
front part of the head examined in the same 
manner. 

In treating a case like this, it is advisable not 
to have the hair cut too short, but to keep it about 
two inches long. The stumps are then more 
easily observed, as the long hair is held back with 
the fingers; if the hair is too short, it is im- 
possible to hold it down. 

The child should be seen about once a week, 
and an attempt made to pull out each stump as it 
comes into view ; if it break off — which is most 
probable — a minute drop of croton oil should at 
once be applied and pressed into the follicle. At 
the next examination, the oil must again be put 
into the follicles of the stumps that break off, as 
well as into those of any stumps, which have not 
before been treated. In an extensive case, this 
may have to be done for many weeks, or months. 



THE TREATMENT OF DISSEMINATED BINGWOEM. 183 

before a complete cure can be effected. If the 
majority of the stumps break off, I generally apply 
a minute drop of croton oil to the follicles of the 
others hefore I attempt to extract them. For, if 
this plan be not adopted, the exact position of the 
follicle when the stump is broken off in it, is 
unseen; and nothing more can be done till the 
stump re-appears again above the surface of the 
scalp. If the needle point, covered with oil, can 
be passed into the hair-follicle, this little operation 
rarely fails to loosen the diseased stump. 

It is also advisable to have the scalp well bathed 
with hot water for ten minutes before commencing 
to extract the diseased hairs ; and also to have a 
small basin, with a sponge and some water in it, 
on a small table by the right hand side of the ex- 
aminer, on which to wipe off the extracted stumps 
from the forceps. 

During the treatment, if there are very many 
stumps to be seen, I prefer — but it is not essential 
— to have the hair kept only about an inch and a 
half long, and a large thin poultice worn, day and 
night, under an oilskin cap. The constant heat 
and moisture very much help the croton oil to 
produce the necessary pustulation, and, by pre- 
venting the spots from drying, render the extrac- 
tion of the stumps easier. 



184 CHBONIC BINGWOBM : ITS TBXATKENT. 

It is also necessary to use some mild parasiti- 
cide over the entire scalp, either oleate of mercury 
(five per cent, ointment), carbolic oil or glycerine 
(one to seven), or salicylic acid ointment (twenty 
to forty grains to the ounce). 

This treatment should be continued until a 
month has passed by without any stumps being 
seen, and then the case may be considered well ; 
but even then it is better to examine the place 
once more in a month or two, as one or two 
stumps may re-appear. 

Sometimes a few follicles may have been de- 
stroyed by extra severe treatment, when of course 
a very small bald place may remain, but no stumps 
or mintUe black dots should be visible upon it, 

I have often succeeded in curing extensive cases 
of disseminated ringworm, when they have resisted 
all other treatment for years, but it requires 
much time and attention. It is well for medical 
men to remember that it is useless for them to 
attempt to cure this variety of chronic ringworm 
by means of croton oil, unless they thoroughly 
realise how intractable the disease is, possess a 
good lens, and good eyesight, and have plenty of 
time and patience. 

For the last few years, I have sometimes used 
a remedy suggested to me by the late Dr. T. Fox, 



TBBATMENT Bt ELECTBOLYSIS. 185 

where there are only a very few minvie patches, 
and where time is of the utmost importance. This 
is a paste made of eqaal parts of crystallised 
terchloride of antimony and lard. It is most 
intensely escharotic, and always produces a bald 
place, by destroying the hair-follicles wherever it 
is applied. Therefore it mvst only he used in very 
exceptianal cases, and to places not larger than the 
head of a large-sized pin. I have even used it to 
a very small and chronic spot, when it was abso- 
lutely necessary to get it cured by a certain time ; 
and sometimes apply a very minute dot of it, with 
the point of a gold needle, to the black spots so 
often mentioned before, as well as to any isolated 
stumps, which cannot be removed by the croton 
oil treatment; but it is certainly better to treat 
such cases by electrolysis. I must again warn 
any one against applying it to too large a spot, as 
it is certain to cause a slough, and therefore a 
bald place ; but it does no harm to destroy a few 
isolated follicles. 

Electiboltsis. — Lately Mr. Malcolm Morris and 
myself have been removing isolated diseased stumps 
by electrolysis. So far the results have been very 
promising; but it is important to remember that 
the process is essentially a destructive one, and 
that no new hair will replace the diseased stump 
removed by this method. 



186 TREATMENT BT ELECIROLTSIS. 

Electrolysis requires great care and experience ; 
for if too strong a current be employed at firsts it 
may cause very unpleasant nervous symptoms^ viz. 
giddiness^ sickness^ &q,, as the current passes 
through the head. 

A very fine sewing needle^ set in a holder con- 
nected with the negative pole of a battery^ is 
introduced into the hair-follicle; and then the 
current is passed through it. The great aim of 
the treatment is to use just sufficient electricity^ 
in order to cauterise the hair-follicle^ without 
producing any sloughing of the skin round it^ 
so that the stump comes away entire. I 
have used from 6 to 12 cells of a Leclanche 
battery^ for half to one minute; but as the results 
vary with each individual, only practical experi- 
ence will enable the operator to find out the 
number of cells and time required. Great care 
must be taken not to employ too strong a current 
at first, and to watch the effects. Of course the 
removal of a number of isolated stumps by elec- 
trolysis takes a long time, but it does not produce 
scars, like the treatment by terchloride of anti- 
mony. 

This method of treatment is only suitable in 
cases in which the diseased hairs are few and 
scattered. 



TREATMENT OP INCURABLE CASES. 187 

Every species of treatment will fail sometimes 
in eradicating extensive disseminated ringworm ; 
and there are undoubtedly inveterate cases that 
cannot be cured, although even these almost 
always get well spontaneously at about the age of 
fifteen to eighteen. I have rarely seen a boy 
leave Christ's Hospital at the age of sixteen or 
seventeen with any diseased stumps remaining on 
his head. 

When I have had such inveterate cases in this 
school, I have continued to use boracic acid, or 
some other parasiticide ; and thus, while they have 
been allowed to attend school, I have prevented 
the disease from spreading to the other boys. 



188 OSNEBAL TKKATMENT. 



CHAPTER XI. 

Gkneral and Constitutional Treatment: 

Scurf after Bingworm : 

The Treatment of Alopecia. 

Obneral Treatment. 

With regard to general treatment, disinfection 
of the clothes is advisable ; and therefore, coats, 
neckties, comforters, etc., ought to be well baked, 
and the linen, underclothing, etc., boiled. Caps 
should have the lining removed and destroy ed^ 
and they should also be well baked, or even burnt 
if old and worthless. Brushes, combs, and towels 
used by the patient, must be kept apart, the 
former being cleansed with carbolic lotion (one in 
twenty), the latter well boiled. 

When one child has become infected with ring- 
worm, if there are other children in the house, 
the most stringent precautions, as regards isola- 
tion, disinfection, etc., ought at once to be taken 
(as directed under ^^ Ringworm in Schools," 
Chapter XII.), or the disease will almost certainly 
spread. 



CONSTITUTIONAL TREATMENT. 189 

The doctor should take an early opportunity of 
carefally examining the heads and bodies of any 
other children in the house ; and at first should 
personally superintend the application of the 
remedies^ and should show the mother or nurse 
how to epilate, and to rub and itresa in the re- 
quired lotion^ ointment^ etc. 

One or other of the preventive lotions^ or oint- 
ments — Vide page 156 — should be applied to the 
heads of the other children^ when one in a family 
or small school has ringworm ; and either can be 
used for months without producing any ill-effect. 

I generally employ the preventive ointment, the 
saturated solution of boracic acid in spirit or car- 
bolic oil (one in eight). 

Great care must also be taken, when carbolic 
glycerine is used, to inform the nurse of the foi- 
80710118 nature of the remedy, so that it may be 
8afely put away when not actually in use. 



Constitutional Tbbatment. 

Internal remedies have no direct effect upon 
the destruction of the fungus, and therefore in- 
ternal treatment is not of much value in ordinary 
ringworm, or in recent cases ; but in the inveterate 



190 8CUBF AFTER BINGWOBM. 

forms^ especially in weakly^ anaemic^ ill-nourished 
children^ of a strumous or lymphatic diathesis^ it 
is advisable to give cod-liver oil and steely together 
with a generous diet^ and other tonics if necessary ; 
and sometimes also arsenic is useful. 

The general nutritive tone should be improved, 
and dyspeptic symptoms, if present, must be 
removed with alkalies and tonics. 

It is a remarkable but certain fact that children 
with chronic ringworm, generally dislike fat. 
Nevertheless it should be given in some form or 
other, as cod-liver oil or cream. Change of air 
also, is sometimes beneficial in chronic cases ; but 
the local treatment is by far the most important. 

It is a mistaken idea that removal to the sea- 
side will help to cure chronic ringworm. It is 
just as prevalent there as at inland places. 

SCUBF AFTER BlNGWOBM. 

As a rule all scurf disappears from patches of 
ringworm, as soon as the disease is perfectly well ; 
but sometimes a place may remain scurfy for a long 
time after the fungus has been destroyed. In a 
case like this, citrine ointment, diluted with three 
to seven parts of lard, should be tried ; and if this 
fail, perhaps glycerine jelly will succeed. 



SCUSF AFTER RINGWORM. 191 

ChroDic scurf, however, is imu:h more likely to be 
due to the disease being still uncured, and therefore 
in a contagious state. In fact most cases of ap' 
parent simple scurfiness, left after treatment, are 
most inveterate forms of chronic ringworm. I con- 
stantly see cases where ringworm had been treated 
for a year or two as chronic scurf or eczema. A 
mother sometimes writes as follows : — " My child 
had ringworm two years ago, and was cured ; but 
ever since then he has had a scurfy head, and in 
some places the hair does not grow as well as I 
should like it to do. Can you advise me any 
treatment to get rid of this troublesome scurf?" 

Therefore medical men should be very careful, 
and not immediately conclude a case is simple 
scurf, or squamous eczema, but should most mi- 
nutely examine the scalp with a lens, to see if there 
are not a few isolated stumps, or even the black 
dots, scattered about, and concealed by the long 
hairs. 



192 THE TSSATMKNT Of ALOPECIA. 

The Tesatkent or Alopecia. 

Parasiticides need not be employed; and the 
treatment can be restricted to local stimulants^ in 
order to increase the growth of the hair. 

Iodine liniment is a favourite remedy with 
many^ and should be applied about every day or 
two to the patchy and for half an inch round it. 
At the same time^ if the hairs easily come out, the 
following lotion may be well dabbed into the 
scalp; if the patches are extensive^ only an 
application now and then of the liniment can be 
borne, but the lotion can be freely used : — 

]]^ Tinct. Canthar., Jij. 
Ac. Acetic. Fort., ^j. 
Glycerin., . . 3iv. 
Sp. Eosmar., . Jj. 
Aq. EosaB, . ad ^ viij. M. Ft. Lot. 

Some physicians advise liq. epispasticus^ and 
then the wash containing cantharides can be 
employed until the new downy hair is again 
growing freely. This new hair may be shaved 
now and then, and the stimulant still applied. 

One of the best applications is turpentine ; this 
can be well rubbed into the patches twice a day, 
with a small sponge mop or stiff brush. 



THE TREATMENT OF ALOPECIA. 193 

The following lotions can also be employed : — 

J^ Tinct. Canthar., . ^j. 
Tinct. Capsici, . . Jj. 
Aq. E0S8B, . . . 2 j. M. 

J^ Liq. Am. Fort., . |j. 
01. Amygd. Dulc, J j. 
Sp. Eosmar., . . ^ iv. M. 

Internally, iron, quinine, arsenic, and other 
tonics may be given. 



194 BINGWOBM IN SCHOOLS. 



CHAPTER XII. 
Ringworm in Schools. 

including thb questioics op "cbrtificates" axd 
''isolation:'' qbnebjll bulss to be observed 15 
schools: general rules to be observed by 
parents: precautions to be observed, if a case of 
ri>*gw0r1[ appear in a family or a school! 0e5- 
eral treatment of thb infected cases. 

I AM of opinion that the Principal of every pro- 
perly managed school^ on the first admission of a 
pupil^ should insist that the usual certificate of 
healthy signed by a medical man^ should state 
that he has made a thorough examination ofihe 
child's head and body, and that no trace of ring- 
worm exists. An ordinary certificate, saying the 
pupil is in good bodily health, and free from 
infectious and contagious disease, is not suflScient, 
as it probably has been granted without any 
special examination of the head, and generally 
without undressing the child. Of course in large 
schools, where there is a Medical Officer, this cer- 
tificate can be dispensed with, as he should most 



WHEN MAY CHILDREN GO TO SCHOOL? 195 

cerfcainly examine every boy and girl before ad- 
mission^ and reject any who are still suffering 
from ringworm. 

Children having any form of the disease should 
not be admitted into a school until they are quite 
cured {Vide p. 38) ; except^ perhaps, when a child 
has been thoroughly well treated for a year or 
more, and yet Bkfew isolated stumps remain that 
cannot be immediately removed, at any rate under 
the usual treatment, even of the most skilful kind. 
These special chronic cases are brought up — as I 
too well know — for admission into Public Schools 
at short intervals, during one or even two years, 
although constantly under the best medical treat- 
ment. What is to be done with such cases? 
With regard to Christ's Hospital, when boys 
reach a certain age they cannot be admitted, and 
therefore the time arrives sooner or later when a 
boy must either lose his presentation, or be passed 
into the junior school with a few isolated stumps 
still remaining. When this time arrives, I advise 
admission into this particular school rather than 
that a presentation should be lost; as I am 
strongly of opinion that these cases can be ad- 
mitted with comparative safety to the other boys, 
provided they are regularly looked after, and 
some parasiticide (such as boracic acid lotion, 

o2 



196 BJNOWOBM IN SCHOOLS. 

oleate^ or carbolic glycerine) be used to the head, 
while the stumps are being removed by the croton 
oil treatment. I have had boys in the London 
school under these circumstances^ and have not 
found that they have spread the disease. Again, 
it must be remembered that if chronic cases be 
admitted into a school^ even when they are ap- 
parently perfectly free from all stumps^ they very 
often relapse ; and thus a boy who has suffered 
from chronic ringworm before his admission, is 
very likely to have isolated stumps re-appearing 
for weeks, or even months. 

For the same reason, I always allow a boy al- 
ready in this school, who is suffering from dissemi- 
nated ringworm of an inveterate character bid 
under proper supervision and treatment, to mix 
with the other boys, and firmly believe it is a safe 
course to follow. I feel confident that the rest of 
the boys in a school run far less risk of taking the 
disease from these disseminated cases {under proper 
supervision and treatment), than they do from 
mixing with other children in private families. 
For such children often have ringworm without 
their parents being aware of the fact, and, as they 
are not under any treatment, the disease exists in 
a much more contagious form, and is infinitely 
more likely to be conveyed to others, than it 



MEDICAL CERTIFICATES. 197 

would be if they were under a doctor's care. The 
number of children having ringworm unknown 
to their parents or friends, is shown by the fact, 
that boys, supposed to be free from the disease, 
and who are brought for admission into this 
school from all ranks, are found to have ringworm 
in the proportion of eight per cent. {Vide pages 
49 to 53). 

Nevertheless, I consider it extremely wrong to 
send children, not absolutely well into any school, 
unless they are under very special treatment, and 
the facts of the case are known to, and approved 
by, either the Medical Officer, or the Principal of 
the school. It is quite useless for Principals of 
ficbools to refuse to have such cases (under special 
care and treatment) returned to school, while boys, 
with large patches of chronic ringworm in a highly 
contagious form, are freely admitted under an 
ordinary medical certificate. 

There is not the least doubt that children are 
constantly sent back to schools, even with a medical 
certificate — stating that the ringworm is now cured, 
and that the child cannot convey the affection to 
other children — when the disease is in a most 
chronic, and certainly in a highly contagious state. 
Thus ringworm may be unwittingly introduced, 
and spread widely before the cause is discovered. 



198 BINGWOBH IN SCHOOLS. 

I have many times found twenty per cent of 
the boys^ even in a private school^ with ringworm 
of the head ! 

This is almost always due to the admission into 
it of an nnsnspected case or two of chronic ring- 
worm. Some time since^ I examined all the boys 
belonging to a first-class school (where they had 
had several new cases of ringworm during the past 
months)^ at the commencement of a school term^ 
and found ten boys out of foriy-eight with tinea 
tonsurans. Some of these boys had been sent 
back to school with medical certificates saying 
they were cured of the complaint. 

The most suspicious certificate is one in which 
it is stated^ that a boy is free from ringworm^ but 
still has a little chronic scurf or eczema remaining, 
and that the ointment advised had better be em- 
ployed to prevent any recurrence of the disease. 
If the ringworm is cured, a pupil requires no 
ointment, or certainly not one containing parasiti- 
cides, to apply to "scurf" or "eczema." 

In fact, I am continually seeing cases of ring- 
worm, where great mistakes have been made as to 
their being cured; and by far the majority of 
children with inveterate ringworm that come 
under my notice, have abeady been certified as 
'^ perfectly well." 



CAUSES OF filNGWOBM IN SCHOOLS. 19D 

Outbreaks in private schools are constantly due 
to boys being sent back^ after having had ring- 
worm, with incorrect medical certificates, when, 
in fact, they are sufiFering from chronic and con- 
tagious forms of the disease. 

If medical men would only consider what in- 
justice it is to the Principal of a school, and what 
disastrous consequences may follow such a certifi- 
cate, I feel sure they would pay more attention to 
this subject. Sometimes the Principal of a private 
school is seriously embarrassed, and put to great 
annoyance and pecuniary loss, by an outbreak of 
ringworm, which is due to no lack of precautions 
on his part, but simply to his implicit belief in a 
medical certificate. 

Again, a succession of outbreaks in a school, in 
spite of every precaution being taken — including 
immediate and complete isolation — thorough dis- 
infection — daily examinations — and the use of a 
preventive ointment— mny be due to a boy, who 
all the time is actually under treatment for a spot 
of supposed scurf, or chronic eczema. Thus the 
very means used to prevent the spread of the dis- 
ease — viz,, the nurse rubbing each head with a 
preventive ointment — may actually be the cause 
of a succession of fresh cases. 

I trust my medical brethren will forgive me for 



200 OBNEBAL BULBS TO BJB OBSERVED IN SCHOOLS. 

speaking so strongly on this matter^ bat I can 
assure them it is only from a sense of daty^ and 
with a thorough knoinrledge of facts which justify 
the foregoing remarks. 

General Bules to be Observed in Schools. 

The school matron^ or other person in charge of 
a certain number of young boys or girls, ought to 
examine the head, and upper part of the body, 
of every pupil, directly they return to school after 
the holidays; as during their absence they may 
have caught the disease. 

In large Institutions, this examination may be 
repeated every week during term time ; and any 
child with a suspicious spot should at once be sent 
to the doctor for his opinion. 

Children at school ought always to have separ- 
ate washing flannels, towels, brushes, combs, etc., 
and the heads should be washed regularly, as well 
as the body, on " bath nights." 

It is also advisable to have all hair-cutting 
operations performed inside the school, whereby 
all risk of infection from without will be avoided; 
And the hair-cutter should use the brush and 
comb belonging to each boy ; or, in large estab- 
lishments, a separate one for each distinct set of 



PBBCAUTIONS TO BE OBSBBVED. 201 

boys. Care should also be taken aboat tbe scis- 
sors, and the cloths {Vide page 4). 

Genebal Bules to be Obsebyed by Pabents. 

Parents should be careful not to receive other 
people's children into their houses, who are suf- 
fering from ringworm, nor even those who are 
known to have had the disease, unless it is quite 
certain that the affection is thoroughly eradicated. 

Parents should also have their children's heads 
carefully examined when they return from school, 
as it is not at all impossible that they may be suf- 
fering from undetected ringworm. 

It is also advisable not to send children to the 
hair-dresser, but to have him to the house, and 
insist on his using the scissors, brush, and comb 
belonging to the house. 

Children with ringworm-in any stage— ought 
never to be taken either to the hair-dresser's, or 
the hatter's. 

Pbecautions to be Obsebved if a Case of Bino- 

WOBM ApFEAB in a ScHOOL, OB A FaMILT. 

When ringworm actually breaks out in a school, 
or a family of children, besides the general treat- 



202 BTKOWORM IN SCHOOLS. 

ment already mentioned (p. 200)^ especially the 
keeping separate the combs^ brushes, towels^ etc. ; 
a careful examination of every child ought to be 
made by some one who thoroughly understands the 
appearance of ringworm in its earliest stage, as 
well as of the chronic and disseminated varieties. 
All cases detected should at once be isolated in a 
separate building, or portion of the house. I 
believe the complete isolation of recent cases to be 
most desirable. 

Then the woollen clothes, comforters, etc., espe- 
cially the cap of each infected child, ought to be 
disinfected by baking, or by burning sulphur ; and 
the brush and comb should be removed from the 
general sleeping apartment, and, after being 
cleansed with carbolic lotion, set apart for the 
ohild^s use during treatment. The bed-clothes 
and linen should be sent to the laundress, and 
directions given for it to be boiled separately. 

If many cases have occurred, the room or dor- 
mitory should be fumigated by burning sulphur 
in it. 

But the most important point of all is the exami- 
nation of the supposed healthy children ; as I 
almost always find that an outbreak in a school is 
due to a chronic case having been overlooked. Of 
course it is quite useless taking all the above pre- 



PRECAUTIONS TO BB OBSERVED. 203 

cautions^ if a single case of disseminated or chronic 
ringworm be allowed to remain undetected. 

If the disease spread in spite of isolation^ the 
best plan is to rub the preventive ointment (Fide p. 
157) on the heads of all the non-infected children^ 
as greasy applications are of use in preventing the 
spread of the disease. It is of the utmost import- 
ance that the nurse who does this should not be 
the one who is attending to the infected cases. 

It is also advisable to insist on the thorough 
washing of all the heads with carbolic acid soap 
(ten per cent.) once a week^ and the disinfection 
of the rooms by burning sulphur in them. 

The dietary should also be seen to^ as the un- 
der-fed, and ill-nourished, are the most prone to 
take the complaint. If the children are pallid, an 
extra allowance of meat should be given, with iron, 
and perhaps cod-liver oil. The proper amount of 
cubic space, and ventilation of apartments must 
also bo attended to, if the disease is increasing, as 
it may possibly be due to the fungus being blown 
about with the dust in the wards. Dr. T. Fox 
has conclusively shown that this may be the cause 
of ringworm spreading in schools. 

These precautions will almost certainly stop the 
spread of the disease; and if they are not effectual, 
in all probability there is an undetected case of 



204 BINGWOBX IN SCHOOLS. 

chronic ringworm still existing among the sup- 
posed healthy children. ' 

An intelligent norse ought to be employed to 
rab in the preventive ointment; and she should 
be taught to recognise any small place of ringworm 
in its early stage^ or else she may help to spread 
the complaint^ by first rubbing a boy's head who 
has recent ringworm^ and then that of a non-in- 
fected child. Of course, if one boy has unde- 
tected chronic or disseminated ringworm, it is not 
the nurse's fault if other boys become infected, 
as sometimes the ringworm fungus will be im- 
planted, and develop on a child's head, in spite 
of a preventive ointment. {Vide p. 199). 



General Treatment of the Infected Cases 

IN A School. 

Pupils with ringworm should be sent home for 
treatment, or isolated in a separate building, or a 
distinct part of the house. A special nurse ought 
to have charge of them; and, if they are very 
numerous, it is better to divide the cases into the 
recent and slight, those that are more severe, and 
those that are nearly well. 



WHEN MIX AGAIN WITH HEALTHY CHILDREN ? 205 

The linen should be well boiled and washed 
apart from the general linen of the school. 

The hair- cutter should cut the hair of the in- 
fected children last, and use the special comb and 
brush belonging to each child^ as well as special 
scissors and cloth. 



When may a Child again mix with Healthy 

Children ? 

The most difficult point of all is to decide when 
a child, who has had ringworm, may again mix 
with healthy children. There is no doubt it is the 
safest plan to keep the patient separate till abso- 
lutely well, which can only be determined by the 
complete absence of stumps and black dots, and 
the growth of the new downy hair on the patches, 
as before described (page 38). But though I con- 
sider it quite justifiable to allow a child with only 
a few stumps to mix with other children, provided 
the case is under efficient treatment {Vide p. 195), 
yet I do not think it right for ordinary cases of 
recent or chronic ringworm to be allowed to 
return to school during treatment. 

The question is now and then raised whether 



206 BINGWOBM IK SCHOOLS. 

children nnder medical care can give the dis- 
ease to others? No donbt they can^ yet ring- 
worm is usnally given by cases not nnder any 
treatment; bnt^ as I have so often maintained^ it 
is useless to keep children who have ordinary 
ringworm nnder efficient treatment from school^ 
and to allow others who have untreated and 
chronic forms of the disease to return and freely 
mix with the healthy children. There is no doubt 
which class would do the most harm. 

There was a correspondence on this subject in 
Ths Lancet (commencing Feb. llth^ 1882)^ sug- 
gesting that if the spores were mechanically fixed 
by fat^ the disease would not spread; but the 
reply was easy. ''The old system of covering 
the patches with ointments of various kinds, has 
been tried for years in the schools of England, 
and with what success every Medical Officer 
knows well''. Again what would schoolmasters 
say, if boys were returned to schools to wear skull- 
caps, thus showing that they had an infectious 
complaint ; or, what is more to the point, what 
would the parents of other boys in the school have 
to say on the subject? Would that school be 
likely to increase in numbers the following term ? 
No — ^isolation is the best way of stamping out this 
rapidly increasing and troublesome complaint in 



WHEN TO RETURN TO SCHOOL. 207 

our private, as well as in our Board and Elementary 
schools. But until something is done to isolate 
the infected children, or to medically supervise 
the lower class schools, where such a large 
per-centage exists, there is but little hope of 
even lessening this scourge. 

It is certainly not right to subject healthy child- 
ren to the risk of taking such a troublesome dis- 
ease as ringworm ; so that while fully believing 
that by far the majority of cases are contracted by 
contact with those who have untreated ringworm, 
and that it is quite possible to treat one or two 
cases in a family or school without the complaint 
spreading, yet I do not think it right or just to 
expect Principals of schools to receive ordinary 
cases back among their healthy pupils, even 
though they are under the most efficient treat- 
ment. 

There is one point of especial importance in 
deciding at what stage it is justifiable to allow an 
infected child to return amongst the healthy; 
viz.; — the age of the children with whom the 
uncured case will have to mix. It is a well 
known fact that ringworm spreads much more 
readily amongst children under eleven, than 
amongst those who are older, and that they rarely 
take the disease after the age of thirteen. There- 



208 BIKGWOBM IN SCHOOLS. 

fore I consider it might be quite proper to ad- 
mit a case, with only a few stumps remaining, 
into a school where all the pupils were over eleven 
or twelve years of age, while it might be wrong 
to do so if they were under eleven. 



PRESCRimONS. 



Fob BiNawoBu of the Bodt. 
{Vide page 89). 

1. U; Acid. Acetic. Fort., . . 3iv. 

Liniment. lodinii, . . 3 ij. M. 

2. Jj^ Acid. Acetic. Fort.. 

3. Jji Tinct. lodinii, 

Liniment. lodinii, . . aa ^ ss. M. 

4. Jjt, lodinii, 3ij« 

01. Jnnip. Pyrolig., ad . J j. M. 
Modified Coster's Paste. 

5. U Hydrarg. Perchlorid.,* gr. ij. vel iij. 

Sp. Vini Beet., . . q. s. 

Adip. Benzoat., • . Jj. M. Ft. Ung. 

(^ To be dissolved in the alcohol before it is mixed 
with the lard). 

6. R Hydrarg. Perchlorid., . gr. j. ad iij. 

Sp. Vini Beet., . . . ^j- M. Ft. Lot. 

p 



210 PRtSCBIFTIONS. 

7. B Acid. Chiysophanic, . . gr. vi. 

Chloiofonn. (Meth.), . . |j. M. 

8. S Chrysarobine. 

' Kemp d CoCt Bomb€ttf Cfoa Powder), 

9. A Aeid. Guysoplianic., gr. v. 

Adip. BeuEoat., . . ^ j. M. Ft. Ung. 

10. B Hydrarg. Oleat., 

FW Gnpri Oleat., . 3j. 

(Dr. Shoemaker's). 
Adip. Benzoat., . 3 vii. M. Ft. Ung. 
{Vide p. 142). 

11. ft Acid. Garbolici, . . 3j- 

(Calvepfs No. 2). 
Glycer. AmyU, . . 3 v. ad 3 vij. M. 

12. II Acid. Sulphnrosi, 

Glycerin, . . • aa |j. M. Ft. Lot. 

18. B Ung. Hydrarg. Nitrat., 3j> 

Adip. Benzoat., 3 i* ad 3 vij. M. Ft. Ung. 

14. B Acid. Boracici, . . 3 iv. 

Aquae, . . . . Jiv. M. Ft. Lot. 

15. B Zii^ci Sulphat., . . 3 iv. 

Aquae, . . . . Jiv. M. Ft. Lot. 

16. U Boro-glyceride, 

Glycerin., . . . . aa | ss. M. 



PBE8CEIFT10NS. 211 



Fob Recent Einowobm of the Head : 
Small Places Only. 

17. B; Acid. Ghrysophanic, . . gr. xiv. 

(Chrysarobin). 
Chloroform. (Meth.), • . ^ ^- ^* 
{Vide p. 108). 

18. ^ Hydrarg. Perchlorid., . gr, ii. ad iv. 

Sp. Yini Beet., . . . ^ i. M. 
{Vide, p. 118). 

19. B *Hydrarg. Perchlorid., . gr. iv. ad vi. 

Acid. Acetic. Glac, . . fj. M. 
{Vide pp. 112, 118). 

20. '^ ^Liq. Epispastic.. 

21. B *Acid. Acetic. Glac. 

22. B tHydrarg. Perchlorid., . . gr. ij. ad iv. 

Acid. Acetic. Fort., . . Jj. M. 

28. ^ +Acid. Acetic. Fort.. 

24. Jfe Hydrarg. Perchlorid., | gr. ii. ad v. 

Sp. Vini Beet., . . . q. s. 

Adip. Benzoat., . . ? j. M. Ft. Ung. 
{I To be dissolved in the alcohol before it is mixed 
with the lard). 

{Vide p. 118). 

• Strong Vesicants, {Fide p. 111), 
t Vesicants. 

1'2 



212 PBiacuFnoNS. 

2». S ChiTsaiofaine. 

(Kimp d Co: 9 Bcmboif Goa Powder). 

{Tids p. 126). 

26. B Add. Bormcici, . . . gr. 1. vel q. s. 

^th. Snlph. (Ifeth.), . ^ j. 
8p. ^^ni Beet., . ad ^iv. M. 
Ft. Solntio saturata limpida. 

{Vide p. 118). 

27. JQt Acid. Salicylic^ ... 3 iiss. ad 3 iv. 

iBth. Snlph. ^Meth.) , . J j . 
Sp. Vini Beet.,. . • ad ^ iv. 
M. Ft. Lotio. 

(Tide p. 111). 

28. ^ Acid. Garbolici., . . . . ? 

(Calvert's No. 2.) 
Glycerin., ? M. 

{Vide p. 118 for proportions). 

29. B lodinii, 3ij. 

01. Picis. Liq., . . .ad Jj. M. 

Coster's Paste, {Vide p. 116). 

80. B lodinii, 3ii. 

Greasoti, .... ad J i. M. 

(Ftrf^p. 116). 



PBESCRIPTIONS. 213 



Fob Beoent Eingwobm op the Head : 
When Extensive. 

81. Ji Acid. Boracici, ... 3 iv. vel q. s. 

Mik. Sulph. (Meth.), . | v. 
8p. Vini Beet., . . ad ^ xx. M. 
Ft. Solntio saturata limpida. 

{Videj^. 118). 

82. R Lot. Acid. SaUcyl. ; Vide No. 27. 
88. Jfc CupriOIeat. ; 7id« No. 45. 

Carbolic Add, Citriney and Sulphur Ointment. 

84. {{; Acid. Carbolici, . . . ? 

{Calvert's No. 2). 
Ung. Hydrarg. Nitrat., ? 
Ung. Sulphuris, . . . ? M. Ft. Ung. 
{Vide p. 124 for proportions). 

Note. — The citrine ointment must be quite free 
from nncombined nitric acid ; no heat must be 
applied ; and the carbolic acid and sulphur ointment 
should be well mixed first, and then the citrine 
rubbed in last. (Vide p. 124). 

85. R Creasoti, |j. 

01. Terebinth., . . . ^ iii. M. 
{VUe^. 180). 



214 PBiscsipnoNs. 

86. Jt Greasoti, . . . . |j. 

Adip. Benzoat., . • |iij. M. Ft. Ung. 

87. B Add. Snlphnrosi, 

A^aae, . . . . aa |iv. M. Ft. Lot. 
(Vide p. 180). 

88. B Thymol, 

Fel Menthol, ... Siv. 
^th. Sulph., . ; 3 ii. 
Sp. Yini Eect., . ad | yiii. M. Ft. Lot. 
(Vide p. 131). 

89. B T. Feiri Perchlor.. 

40. ft 01. Terebinth.. 

(Vide p. 182). 

41. * IJ Cupri Snlphat., . . gr. x. ad xx. 

01. Jnnip. Pyrolig., . 3 iij. 

Snlphur., . . . . Jiij. 

Hydrarg. Ammon., . gr. v. ad xx. 

Adip. Benzoat., . . |j. M. Ft. Ung. 

42. * ft 01. Junip. Pyrolig., . 3 iij. 

Sulphur., . . . . 3iij. 
Tinct. lodinii, . . . S iij. 
Acid. Garbolici, . . rrix. ad xl^ 
Adip. Benzoat., . . ^ j. M. Ft. Ung. 
( Useful in cases of irritable scalp), 

* Favourite remedies of the late Dr. Tilbury Fox. 



PBBSCRIFTIONS. 215 

48. Jfc Boro-Glyceride, 

(Barfj. 
Glycerin., . . aa |i. M. 

(Very useful with pustular eczema and ringworm). 



Fob Chbonio Bingwobm of the Head. 

44. U; Lot. Acid. Boracici. Vide No. 81. 

45. Jfc Cupri Oleat.,* . . . 3 v. ad 3 xii. 

(Dr. Shoemaker*s). 

Otto Bos89 Vrrg., . . gt. x. 

Adip. Benzoat., . .ad ^ v. M. Ft. Ung. 

(Melt the lard by the help of a water bath, and 
stir in the oleate until completely dissolved.) 

{Vide p. 146). 

46. R Hydrarg. Oleat.,* . ^ss. adj. 

(Dr. Shoemaker's). 

Otto BosflB Virg., . . gt. x. 

Adip. Benzoat., ad J v. M. Ft. Ung. 

(The lard to be just melted, then the oleate is to 
be well incorporated, without the appUcation of far- 
ther heat). 

(Jidej^. 140). 
* Can be obtained at Messrs. Corbyn &Co., 300 Holborn 



216 PRESCRIPTIONS. 

The old preparation of oleaie of mercury. 

47. 'St Hydrarg. Oleat., ... J iiiss. 

(10 per-cent. solution), 
^th. Acetic, . . . . ^ ss. M. 

{Vide p. 140). 

48. IJ 01. Crotonis. 

{Vide p. 160). 



Preventive Ointments and Lotions. 

49. Jt Hydrarg. Ammon., . gr. xl.* 

Hydrarg. Ox. Eub., . gr. xx.* 

01. Amygd. Essent., 

Vel Otto EossB Virg., . gt. viii. 

Adip. Benzoat., . . | iv. M. Ft. Ung. 

(** To be finely levigated). 

Sig, — To be used all over the head as a preventive 
ointment. 

50. Jji Acid. Boracici, . . 3 ivss. vel q. s. 

Sp. Vini Eect., . , |xx. 
M. Ft. Solutio saturata limpida. 

51. Jjt Hydrarg. Perchlorid., . . . gr. j. 

Adip. Benzoat., Jj. 



PRESCBIPTIONF. 217 

52. JH Acid. Carbolici, ... 3 vii. 

Glycerin, vel 01. olivsB ad J viii. M. 
Sig. — To be used all over the head. 



68. Jt SodsB HypoBulph., . . J ij. 

Aquae, J viii. 

M. Ft. Lot. 



64. 5; Acid. Sulphurosi, . . ^ ij. 

Aq., ad 2 viii. 

M. Ft. Lot. 



65. Jjt, Acid. Salicylic, . . . gr. xl. ad 3 ij. 
Adip. Benz., 

Vel Aquae, . . . . J iv. 
M. Ft. Ung., vel Lot. 

56. U Boro-glyceride, |j. 

Glycerin., Jij. M. 

57. H Liq. SodsB Clilorid., . . | j. ad ^ij. 

Aq., ad 3 viii. 

M. Ft. Lot. 



218 



FBESCBIFTI0N8. 



Fob Alopecia Akwata. 



1^ Lin. lodinii. 



^ Tinct. Canthar., 
Ac. Acetic. Fort., 
Glycerin., . . 
Sp. Bosmar., 
Aq. Eosae, . . 

T^ Liq. Epispast.. 



. 3iv. 
ad J viii. M. Ft. Lot. 



R 01. Terebinth.. 

J{; Tinct. Canthar., . . Jj. 

Tinct. Gapsici., . . ^j. 

Aq. Eosae, . . . ^j. M. 



U Liq. Ammon. Fort., 
01. Amygd. Dole, 
Sp. Eosmar., . 






M. 



INDEX. 



AbsoesSy kerion resembles one, 

170 
^^ saboataneons, 177 
Absorption of carbolic add, 115 

— of oleate of mercnry, 145 
Acetic acid, 89, 115 
glacial, 112 

— ether, with oleatOt 140 
Ages at which ringworm is con- 
tracted, 7» 48 

gets well, 48 

Air, change of, 190 

Alopecia areata, or circum- 
scripta, 63, 71 ^ 

admission into schools, 

68 

and ringworm co-exist- 
ing, 65 

causes of, 68, 72 

^— diagnosis of, 69 

microscopical examin- 
ation of stamps, 70 

mixed cases of, and 

ringworm, 65 

— nature of, 64 

often mistaken for 

ringworm, 69 

parasitic or not ? 65 

stumps in, 70 

^- — treatment of, 192 
Animals, may gire ringworm, 6, 

74,81 
Antimony terchloride, 185 
Application of remedies, 150 



Artificial production of kerion 

vide Kenon 
Atrophied stumps, 41 



B 



Bald places with ringworm, 20 
spots caused by croton oil, 

169, 172, 176, 184 
— -* diagnosis from ring- 
worm, 62 
temporary after kerion, 

164, 166 

with ringworm, 20 

Beard, ringworm of, 73 
Bent hairs in alopecia, 70 

in ringworm, 19 

Bichloride of mercury, 90, 93, 

112, 113 
Black dots, 31, 97 

— treatment of, 179 

Blistering, 111 
Body ringworm, 7, 73 

causes of contagion, 73 

description of, 74 

diagnosis from eczema, 

84 

from erythema, 84 

— from favus, 88 

_. from herpes, 85 

from lichen circi- 

natus, 86 

• from pityriasis, 83 

_. from pityriasis 

maoulata et circinata, 86 



220 



INDEX. 



ody rin^orm, diagnods from 
pit jriuu Tenioolor, 87 

from pioriasis, 83 

— from teborrhcea, 

88 
— — ^^ from flyphilitic 
einption^ 88 

lodsof, 74y 82 

etiologTa 78 

genenl treatment of, 

94 

— mioroscopioal examin- 
ation of Boales, 76 

parts attacked, 78 

pathology, 76 

transmitted from ani- 
mals, 6, 74, 81 

—— treatinent of, 89 

anoommon forms of, 78 

; — when oared, 95 

Boraoic acid lotion causing alo- 
pecia, 65, 189 

for body ring- 
worm, 90 

• for chronic ring. 

worm, 139 

for recent ring- 
worm, 118 

Boro-glyoeride, 90, 132, 135 

Broken hairs; vide Stumps 

Brushes, 200 

Bulb, broken off in follicle, 83 

conidia penetrating, 27 

Burmese ringworm, 79 







Can a child have ringworm twice? 
46 

Gantharidis hair wash, 192 

Gaps, 149 

Carbolic acid, absorption of, 1 15 

Carbolic acid, treatment by, 90, 
113 

citrine and sulphur 

ments, 123 

' glycerine for body ring- 
worm, 90 



Garbolio glycerine, for scalp ring- 
worm, 118 

Causes of alopecia, 68, 72 

of ringworm, 4, 73 

Certificates, medical, 80, 86, 88, 
194,198 

for schools, 194 

suspicious certificates, 

198 

when cured, 38 

Children, avoid strong remedies 
with, 108 

susceptible to ringworm, 18, 

47 
Chinese ringworm, 79 
Chloroform, 108 

Christ's Hospital, tables of per- 
centage in admission cases, 50 
Chronic ringworm, 29 

best remedies for, 186 

diagnosis of, 29, 44 

difficulty in curing, 

186 

diffuse, 35 

disseminated, 34 

pustular, 35 

treatment of, 136 

Citrine ointment^ 90, 123 

Classes having ringworm, 14, 47 

Clothes, disinfection of, 188 

God-liver oil, 190 

Combs, 188 

Conidia, diagnosis between, and 

oil globules, 26 

description of, 26 

»— - existing at bottom of the 

folUcles, 137 
Conidia, in recent ringworm, 26 

size of, 26, 62, 77 

Constitutional treatment, 189 
Contagion through the air, 5 
Contagious impetigo, 21 
nature of ringworm, proof 

of, 5 

when moat eo, 48 

Copper oleate, 122, 146 

cauring irritation and 

pimples, 148 

^— treatment by, 146 

• sulphate, 188 



INDEX. 



221 



Corrosive sublimate for body 

ringworm, 90, 93 
for scalp ringworm, 

112, 113 
Coster's paste, 115 

— modified, 89 

Creasote, treatment by, 116, 130 
Croton oil, accidents during use, 

165, 167, 169, 172 

age to use it, 174 

applied to recent ringworm, 

23 
causing a sloQgb, 163, 169, 

172. 175 

for black dots, 161, 179 

for disseminated, 179 

for isolated stumps, 160, 179 

p^at aim of treatment, 163 

improper use of, 23 

liniment of, 173 

treatment by, 160 

Crusting inpetiginous eczema, 

20,53 

treatment of, 134 

Crusts, removal of, 154 
Cabic space, 203 
Cultivation of tbe fungus, 9 
Cured, apparently from Goa pow- 
der, 55, 128 

spontaneously, 23 

^— when is ringworm of the 



body cured P 95 
— when is ringworm 
head cured ? S^S 



of the 



Diagnosis between fat cells and 

conidia, 26 

by washing in ether, 42 

errors in, 20, 29, 30, 37, 89, 

40, 42, 54 

from alopecia areata, 69 

from bald spots, 62 

from favus, 59, 88 

from impetigo contagiosa, 

58 
■ from local scurfiness, 56 
— — from other diseases, 54 



Diagnosis from pityriasis, 57 

from prorigo, 68 

from psoriasis, 58 

from scurf, 55 

from seborrhoea, 57 

from squamous eczema, 58 

of alopecia areata, 63 

of atrophied stumps, 41 

of body ringworm. 74, vide 

Body ringworm 

of chronic ringworm, 29, 44 

of recent ringworm, 17 

of tinea declavans, 69 

of tinea sycosis, 95 

no good examining long 

hairs, 54 

no reliance on hairs being 

loose, 54 

Deep pustular rash, 168, 171 

Dietary, 190, 203 

Difficulty in curing ringworm, 
136 

Diffuse ringworm, 85 

Dirt and ringworm, 48 

Disinfection of clothes, 188, 202 

of dormitories, 202 

Disseminated ringworm, 34 

treatment of, 179 

Dots, bkck, 31 

Dry eczema mistaken for ring- 
worm, 58, 84 

Duration of ringworm, 44 



E 



Eczema, diagnosis from ring- 
worm, 58, S4 

Eczema marginatum, 80 

treatment of, 93 

— o pustular, from Goa powder, 
127 

Electrolysis, 185 

Epilation, 154 

by boradc lotion, 120 

Errors in diagnosis, vide Diag- 
nosis 

Erythema, diagnosis from ring- 
worm, 84 



Ether, washing with, 26 



222 



INDEX. 



Etiology, 4, 78 
Examination of the head, 24 
ExaminationB after the holidays, 
200 

— in ichoolfl, 200 

of the healthy boyt, 202 

— — when ringworm appears in 

a school, 202 
Eztensire chronic ringworm, 

treatment, 186 

— recent ringworm, treatment, 
117 



P 



Fat, diaffnosis from conidia, 26 

— children disliking, 15, 190 
FaTus, diagnosis of, 69, 88 
microscopical examination 

of crusts, 61 
Fish-roe condition Of fangns, 88 
Follicles destroyed hy treatment, 

169, 173, 184 

— limit of penetration of re- 
medies, 187 

plugged by diseased stumps, 

119, 187 
Forceps for epilation, 155 

long, 181 

Fringe to be left, 106 
Fungus, vide Conidia ^ 

— artificial cultivation of, 9 

its action on the hairs, 12 

its action on the skin, 10,76 

its exact nature, 7 

• — - life history, 7 

non-identity with that of 

favus, 10 
proof that ringworm is due 

to it, 5 



G 



General directions during treat- 
ment, 149 
• - — health suffering from oleate 

of mercury, 145 
rules to be observed by 

parents, 20) 



General rules to be obseryed in 

schools, 200 
treatment of body ring- 
worm, 94 
of chronic ringworm, 

188 
of recent ringworm, 

158 
of the infected cases, 

204 
Glacial acetic acid, treatment by, 

112 
Glands swdling from croton oil, 

167 

— from Goa powder, 127 

Glass, magnifying, 181 
Glycerine ana carbolic acid, 90, 

113 
Goa powder, apparent cure from, 

128 
Bombay, 90, 98, 116, 

126 
causing impetiginous 

eczema, 90, 127 

—-^ for body ringworm, 90 

for recent ringworm, 

126 
objections to the use 

of, 90, 127 
Gold pin in disseminated ring- 
worm, 179 
with antimony, 186 



H 



Hair cutting during treatment, 
105, 149 

— in disseminated ring- 
worm, 182 

scanty after croton oil, 169 

172 

Hair the removal of, 105 

Hairs loose, diagnostic value of, 
54 

bent in alopecia, 70 

in ringworm, 19 

growing freely, but disease 

uncured, 29 

shortened, vide Stumps 



INDKX. 



223 



Head, examination of, 24 
^— washing, how often ? 153 
Herpes, diagnosis from ring- 
worm, 85 

ciroinatus, 85 

History, 2 

Horse clipper, miniature, 106 
How long has the ringworm ex- 
isted? 43 
Hyposulphite of soda, 93, 156 



Imi>etiginous eczema» 21, 58 

treatment of, 184 

Impetigo contagiosa, 58 

diagnosis from ring- 
worm, 58 

plus ringworm, 20, 58 

Indian ringworm, 79 

Incubation period, 45 

Incurable casen, 178, 187 

Indications showing the remedy 
is operating beneficially, 158 

Introductory remarks, 1 

on treatment, 102 

Inveterate ringworm, vide 
Chronic and Disseminated. 

— when it may be ad- 
mitted into schools, 195, 205 

Iodine for body ringworm, 89 

for scalp ringworm, 115, 132 

Iron tincture, 132 

Isolated stumps, admitting boys 
with, into schools P 195, 205 

treatment of, 179 

Isolation, 94, 202, 204 

Itohing, a symptom of ringworm, 
19,76 



Kerion, 22, I70 

artificial production of, 160 

destruction of fol- 
licles, 163, 169, 172, 175 

~ great aim of treat- 
ment, 163 



Kerion, artificial production, list 
of cases for, 173 

' precautions to be 

taken, 163, 164 
rash from oil on 

pillow case, 165 

" size of places for, 

164 

sloughing after, 

163, 169, 172, 175 

treatment after- 
wards. 162 

distinction between it and 

pustular eczema, 22 

exact description of, I70 

idiopathic, 22, 167, 170, 177 

treatment of, 176 

occurring accidentally, 167 

■ often difficult to produce. 

168 ' 



Lichen circinatus, diagnosis 

from ringworm, 86 
Life history of fungus, 7 
Linen, what to do with, 188, 202 
Liniment of iodine, 89 
Local scurfiness, 55, 190 



M 



Ttfedical certificates, 194, vide 

Certificates. 
Menthol, 122, 131 
Microscopical examination of 

crusts from favus, 61 
— ; of scales from body 

ringworm, 76 
from pityriasis 

versicolor, 87 
of stumps from alo- 
pecia. 70 
of slumps from chronic 

ringworm, 33 
of stumps from recent 

ringworm, 25 
Miniature horse clipper, 106 



224 



INDSr. 



Mixed cAtet of alopecia and ring- 
worm, 65 
Mjoelium, 27, S4, 77 
of faTus, 61 



N 



Nails, ringworm of, 100 
Nature's care of rin^orm, 160 
Needle gold, vid$ gold pin 
Night-caps, 149 



Oil of cade, S9 

Ointment, carbolic, oitrinet and 

snlphnr, 123 

preventive, 167 

Oleate of copper, 122, 146 

— causing irritation, 148 

causing pimples, 148 

— ^ treatment by, 146 

Oleate of mercury,^ 140 

— causin^r irritation, 148 

ether with, 140 

ill effects from, 145 

— precautions in using, 

144 
Oleates, Dr. Shoemaker^s, 141 

— treatment by, 142 

— — value of, for ringworm, 188, 

140 
washing during treatment, 

144 

— vellow crusts, 148 
Onyohomykosis, 100 



Fftrasitic nature of ringworm, 8 
— ^— (non) of alopecia, 66 

sycosis, description of, 95 

— diagnosis of, 97 

— treatment of, 99 

Pathology, 12, 76^ 
Penetratingpowef of remedies at 
fault, 138 



Per-centage of ringworm among 
boys, 60 

girls, 61 

Percmoride of mercury, 90, 03, 
112, 113 

Period of treatment, 167 

Petroleum, 141 

Pillow-cases saturated with re- 
medy, 143, 160 

Pityriasis, diagnosis from ring- 
worm, 67, 83 

maculata et circinatA, 86 

versicolor, diagnosis from 

ringworm, 87 

Porrigo, 21 

decalvans, 63 

Position for the examination of 
the bead, 24 

Precautions to be observed if 
ringworm appear, 201 

Prescriptions, 209 

Prevention of spreading, 162 

Preventive lotions, and oint- 
ments, 156 

treatment in body ring- 
worm, 94 

in scalp ringworm, 156 

Psoriasis mistaken for body ring- 
worm, 83 

for scalp ringworm, 58 

Pustular eczema, 21 

^-— from Goa powder, 127 

— — set up by the incautious 

use of oroton oil, 23 

treatment of, 134 

ringworm, 21, 85 

Pustulation in minute spots, 174 
182 



B 



Rate of growth in ringworm, 43 
Becent ringworm, 17 

first stage of, 20 

immediate treatment 

of, 105 
treatment of, when ex- 
tensive, 117 



s 



INDEX. 



225 



Recent ringworm, treatment of, 
when one or two places, 108 

typical patches of, 18 

pnstnlar ringworm, 20 

Remedies how to oe applied, 161 
Removal of crusts and scabs, 154 

of the hair, 106 

Rings in ringworm, 76 
Ringworm, ages at which it is 
contracted, 7, 48 

and alopecia co-existing, 65 

at puberty, 48 

^— atrophied stamps in, 41 

black dots in, 81 

causes of, 4 

classes having it, 47 

commnnicated from ani- 
mals, 6, 81, 74 

constitutional treatment of. 



189 



— contagious nature of, 4 

— definition of, 1 

— diagnosis of, vide Diagnosis 

— diffuse, 86 

— disinfection of clothes, 188, 
202 

of rooms, 202 
disseminated, 84 

treatment of, 179 

etiology, 4, 17 

from animals,, 6, 74, 81 

fungus of, vide Oonidia 

— ~ general treatment of body 
ringworm, 94 

of scalp ringworm, 

188 

how long it may have ex 

isted, 43 

in form of pustular spots, 

21,85 
Ringworm in schools, 194 

in schools, boys ought not 

to return unless cured, 195, 207 
causes of outbreaks. 



80, 194 



dietary, 203 

general rules to be ob- 

200 

general treatment of 



served, 

infected casesj 204 



Ringworm in schools, medical 
certificates, vide Certificates 

ordinary cases of rinsr- 

worm not to be admitted, 195, 
206 

precautions to be used 

if ringworm appear, 201 

primary certificates, 

194 

special cases may be 

admitted, 195, 208 

succession of out- 
breaks, 199 

when may boys again 

mix with the healthy ? 206 

— —incurable cases of, 178, 187 

incubation of, 46 

Indian, 79 

— — inveterate, vide Chronic 

its contagious nature, 6 

its diagnosis, vide Diag- 

treatment, vide Treat- 

the beard, vide Tinea 
sycosis 

of the body, vide Body ring- 
worm 

of the head, chronic, vide 

Chronic ringworm 

of the head, recent, vide 

Recent ringworm 

of the nails, 100 

X^r-centage, 49, 63 

plus impetigo, 20 

precautions as regards dis- 
infection, 188, 202 

precautions as regards iso- 
lation, 188, 202 

pustular, 20, 36 

rate of growth, 43 

small spots of, 36 

spreading in spite of treat- 
ment, 13, 22, 134 

stumps, vide Stumps 

those most liable to it, 13 

time it may last, 44 ^ 

time to cure chronic, 104, 

144, 168 




226 



INDEX. 



Riofirworm, time to care recent, 
102, 104, 157 

treatment, vide Treatment 

twice havinff it, 46 

typical patches of body, 76 

typical patches of chronic, 

81 

typical patches of recent, 18 

unknown condition of skin, 

favourable to ringworm, 13 
when cured — ^body ring- 
worm, 95 
when cured — scalp ring- 
worm, 38 

when most contagious, 48 

Rules to be observed by parents, 
201 

to be observed in schools, 

200 



S 



Salicylic acid, treatment by, 130 

Salivation by oleate, 145 

Scabs from blistering, 112 

from croton oil, 162 

from ointment, 126 

fit)m oleate, 140 

removal of, 164 

Scurf, after ringworm, 190 

first stage of ringworm, 19 

Scurf, genersl, 56, 57, 191 

local, 65, 191 

School certificates vide. Certifi- 
cates 

Schools, vide Ringworm in 
schools 

Seborrhoea, diagnosis from ring- 
worm, 57, 83 

Selection of a treatment, 103 

Shaving, 105 

Short hairs, diagnostic value of, 
54 

Sloughing from croton oil, 163, 
169, 172, 175 

Soil, the, 13 

Squamous eczema, mistaken for 
ringworm, 58 

Statistics, 50 



Stumps, 31^ 

atrophied, 41 

breaking off, 40 

examination for, 32 

false appearance of, 56 

fatty degeneration of, 42 

from alopecia, diagnosis of, 

69 
from alopecia, microscopical 

examination of, 70 
hidden among the healthy 

hairs, 32 

length of, 32 

loosened by exudation, 163 

microscopical examination 

of, in chronic ringworm, 83 
microscopical examination 



of, in recent rin^orm, 25 

nests of conidia in, 38 

rubbed down forming black 

dots, 81 
Strumous children liable to ring- 
worm, 14 
Subcutaneous abscess, 169, 177 
Sulphur ointment, 123 
Sulphurous acid for body ring- 
worm, 90, 92 

for scalp ringworm, 180 

Sycosis, vide Tinea Sycosis 
Symptoms of ringworm, vide 
Diagnosis 

itching, 19, 76 

Syphilitic eruptions, diagnosis 
from ringworm, 88 



Tables of per-centage, 50 
Thymol, treatment by, 121, 131 
Time ringworm may exist, 44 
takes to cure chronic, 138, 

144, 157 

takes to cure recent, 157 

Tinea circinata, 7, 73, vide Body 

ringworm 

decalvans, 63, vuZe Alopecia 

kerion, 170, vide Kerion 

sycosis, 95 

description of, 96 



INDEX. 



227 



Tinea sycosis, diagnosis of, 97 

treatment of, 99 

tonsarans, 17, vide Ring- 
worm of head 

trichophytina anguium, 100 



Tokelau ringworm, 79 

Towels, 183, 202 

Treatment, all, sometimes fails, 

178, 1«7 

by acetic acid, 89, 116 

by antimony terchloride, 185 

by artificial production of 

kerion, 160 

by blistering, 111 



by boracio acid, 90, 118, 189 

by boro-glyceride, 90, 182 

by carbouc acid, flk), 118 

by carbolic acid, citrine and 

sulphur ointment, 123 

by carbolic glycerine, 118, 



165 



by carbolic oil, 189 

by ohrysarobine, or chryso- 

phanic acid, 91, 98, 108, 129 

chrysophanic acid in chloro- 
form, 108 

by corrosive sublimate, 90, 

93, 112, 118 

by Coster's paste, 115 

modified, 89 

by creasotCj 116, 130 

by croton oil, 160 

by electrolysis, 185 

by epilation, 154 

by glacial acetic acid, 112 

by Goa powder, 90 

by hyposulphite of soda, 93 

by iodine, 89, 132 

by menthol, 131 

by oleate of copper, 122, 146 

by oleate of mercury, 14i) 

by petroleum oil, 121 

• by preventives, 78 

by salicylic acid, 130 

by sulphate of copper, 183 

by sulphurous acid, 90, 92, 

130 



by thymol, 121, 131 

by tincture of iodine, 89, 132 

by tincture of iron, 132 



Treatment by turpentine, 182 

by vesicants. 111 

constitutional, 189 

essential points of, 15, 102, 

136, 151 

general, 94, 188 

general directions, 149 

how remedies act, 103 

improper use of oroton oil. 



23 



102 



internal, 99, 189 
introductory remarks 



on, 



of alopecia areata, 192 

of blistered surface, 112 

of crusting impetiginous ec - 

zema, 184 

of eczema marginatum, 92 

of kerion, accidentally pro- 
duced, 176 

of parasitic sycosis, 99 

of pustular ringworm, 184 

of ringworm of the beard, 99 

of the body, 89 

of the head, chronic. 



diffuse, 136 
179 



disseminated. 



135 



patches, 117 



extensive, 

recent large 



recent 



small 



patches, 108 

of ringwormof the nails, 101 

of scurf after ringworm, 190 

of tinea decalvans, 192 

kerion, 176 

sycosis, 99 

period of, 157 

- — preventives, 94, 156 

removal of the hair, 106 

results of, often unsatisfac- 
tory, 16 

selection of, 103 

when the scalp gets tender 

and sore, 183 

is first seen, 105 

Tricophyton tonsurans, 3, 7 
Turpentine, 132 

Q2 



228 



INDEX. 



Twisted hain, 19 
Typical patches of body ring- 
worm, 74 

^— — ohronio ring;worm, 80 

recent ringworm, 18 

U 

Uncommon forma of body ring- 
worm, 78 



Varieties of ringworm, 17 
Vesicants, 111 

W 

Washing heads, how often, 163 



Washing linen, 94, 188 

the linen in schools, loo, 



with ether, 42 , , ^ . 

When is ringworm of the body 

cared ? 95 , « no 

. of the head cured r so 

may children who have had 

ringworm again mix vith the 

healthy? 205 , 
most contagions r 4S 



Yonng children, croton oil not 
to be nsed, 174 



Printed by H. K. Lewis, 136 Gower Street, London. 



May, 1885. 



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'PHE PRACTICAL MEDICINE OF TO-DAY: Two 

^ Addresses delivered before the British Medical Association, 
and the Epidemiological Society. Small Svo, is. 6d. 



C. M. JES80P, M.R.G.P. 

Associate of King's College, London ; Brigade Surgeon H«M.*s British Forces. 

A SIATIC CHOLERA, being a Report on an Outbreak of 
'^ Epidemic Cholera in 1876 at a Camp near Murree in India. 
With map, demy Svo, 2s. 6d. 



GEORGE LINDSAY JOHNSON, M.A., M.B., B.C. CANTAB. 

Clinical Assistant, late House Surgeon and Chloroformist, Royal Westminster 

Ophthalmic Hospital. 

A NEW METHOD OF TREATING CHRONIC 
-" GLAUCOMA: Based on Recent Researches into its 
Pathology. With Illustrations and Coloured Frontispiece, 
demy Svo, 3s. 6d. 



10 Catalogue of Works 



RU8T0MJEE NA8ERWANJEE KHOBY, M.D. BRUX., M.R.C.P. 

THE PRINCIPLES AND PRACTICE OF MEDI- 
^ CINE. Second Edition, revised and much enlarged, 2 
vols., large 8vo, aSs. 



NORMAN W. KINQ8LEY, M.D.8., D.D.8. 

President of the Board of Centora of the Sute of New York ; Member of the 
American Academy of Dental Science, &c. 

A TREATISE ON ORAL DEFORMITIES AS A 
BRANCH OF MECHANICAL SURGERY. With over 
350 Dlustrations, 8vo, z6s. 



E. A. KIRBY, M.D., M.R.0.8. 
Late Physician to the Ci^ Dispensary. 

I. 
PHARMACOPCEIA OP SELECTED REMEDIES 
WITH THERAPEUTIC ANNOTATIONS, Notes on 
Alimentation in Disease, Air, Massage, Electricity and other 
Supplementaiy Remedial Agents, and a Clinical Index ; arranged 
as a Handbook for Prescribers. Sixth Edition, enlarged and re- 
vised, demy 4to, 7s, 

II. 

ON THE VALUE OF PHOSPHORUS AS A REMEDY 
FOR LOSS OF NERVE POWER. Fifth Edition, 8vo, 
28 6d. 



J. WICKHAM LEQG, F.R.O.P. 

Assistant Physician to Saint Bartholomew's Hospiul, and Lecturer on 
Pathological Anatomy in the Medical School. 

I. 
AN THE BILE, JAUNDICE, AND BILIOUS DIS- 
^ EASES. With Illustrations in chromo-lithography, 719 
pages, roy. 8vo, 25s. 

II. 

A GUIDE TO THE EXAMINATION OP THE 
URINE ; intended chiefly for Clinical Clerks and Stu- 
dents. Fifth Edition, revised and enlarged, with additional Illus- 
trations, fcap. 8vo, 2s 6d. 

III. 
A TREATISE ON HEMOPHILIA, SOMETIMES 

rv;Aa.Sr^eVP«'^^^ HEREDITARY HEMORRHAGIC 
DIATHESIS. Fcap. 4to, 78 6d, 



Published by H. K. Lewis. U 



DR. GEORGE LEWIN. 

Professor at the Fr. Wilh. University, and Surgeon-in-Chief of the Syphilitic 
Wards and Skin Disease Wards of the Charity Hospital, Berlin. 

THE TREATMENT OP SYPHILIS WITH SUBCU- 
TANEOUS SUBLIMATE INJECTIONS. Translated 
by Dr. Carl Prcbqle, and Dr. E. H. Gale, late Surgeon United 
States Army. Small 8vo, 7s. 



LEWIS'S PRACTICAL SERIES. 

Under this title Mr. Lewis purposes publishing a complete 
series of Monographs embracing the various branches of Medicine 
and Surgery. 

The volumes, written by well-known Hospital Physicians and Surgeons 
recognised as authorities in the subjects of which they treat, are in active pre- 
paration. The works are intended to be of a thoroughly Practical nature, 
calculated to meet the requirements of the general Practitioner, and to present 
the most recent information in a compact and readable form ; the volumes 
will be handsomely got up, issued at low prices, varying with the size of the 
works. 

THE FOLLOWING ARE NOW READY. 

BODILY DEFORMITIES AND THEIR TREATMENT: A 

Handbook of Practical Orthopaedics. By H. A. REEVES, F.R.C.S. Ed., 
Senior Assistant Surgeon and Teacher of Practical Surgery at the London 
Hospital, Surgeon to the Royal Orthopaedic Hospital, etc. With numer- 
ous Illustrations, crown 8vo, 8s. 6d. 

DENTAL SURGERY FOR GENERAL PRACTITIONERS 

AND STUDENTS OF MEDICINE. By ASHLEY W. BARRETT, 
M.B. Lond., M.R.C.S., L.D.S., Dental Surgeon to, and Lecturer on 
Dental Sureerv and Pathology in the Medical School of, the London 
Hospital. With Illustrations, crown 8vo, 3s. 

DISEASES OF THE KIDNEY AND MORBID CONDITIONS 

OF THE URINE DEPENDENT ON FUNCTIONAL DERANGE- 
MENTS. By C. H. RALFE, M.D. Cantab., F.R.C.P. Lond., Assistaat 
Physician to the London Hospital, late Senior Physician to the Seamen's 
Hospital, Greenwich. With Illustrations, crown 8vo. [/n the Prau 

*•* Prospectus of the Series, with Specimen pages, etc., post free on 

application. 



T EWIS'S POCKET MEDICAL VOCABULAI^V. 

^ itn the press. 



Id Oatalogue of Works 

J. 8. LOMBARD, M.D. 

Formerly AsaisUnt Professor o£ Physiology in Harvard College. 

I. 

PXPERIMBNTAL RESEARCHES ON THE RE- 

^ GIONAL TEMPERATURE OF THE HEAD, under 

Conditions of Rest, Intellectual Activity and Emotion. With 
Illustrations, 8vo, 8s. 

II. 

HN THE NORMAL TEMPERATURE OF THE 
^ HEAD. 8vo,58. 



WILLIAM THOMPSON LUSK, A.M., M.D. 

Professor of Obstetrics and Diseases of Women in the Bellevue Hospiul 

Medical College, &c. 

THE SCIENCE AND ART OF MIDWIFERY. Second 
^ Edition, with numerous Illustrations, 8vo, i8s. 



JOHN MACPHERSONi M.D. 

Inspector-General of Hospitals H.M. Bengal Army (Retired). 
Author of " Cholera in its Home," &c. 

ANNALS OF CHOLERA FROM THE EARLIEST 
PERIODS TO THE YEAR 1817. With a map. Demy 
7s. 6d. 



DR. Y. MAGNAN. 

Physician to St. Anne Asylum, Paris; Laureate of the Institute. 

fJN ALCOHOLISM, THE VARIOUS FORMS OF 
^ ALCOHOLIC DELIRIUM AND THEIR TREAT- 
MENT. Translated by W. S. Greenfield, M.D., M.R.C.P. 
8vo, 7s. 6d. 



Published by H. E. Lewis. 13 



A. COWLEY MALLEY, B.A., M.B., B.CH. T.G.D. 

DHOTO-MICROGRAPHY ; including a description of the 
^ Wet Collodion and Gelatino-Bromide Processes, together 
with the best methods of mounting and preparing Microscopic 
Objects for Photo-Micrography. Second Edition, with Illustra- 
tions and Photographs, crown 8vo, 7s. 6d. [y^st published. 



PATRICK MANSON, M.D., CM. 

Amoy, China. 

THE FILARIA SANGUINIS HOMINIS AND CER- 
^ TAIN NEW FORMS OF PARASITIC DISEASE IN 
INDIA, CHINA, AND WARM COUNTRIES. Illustrated 
with Plates, Woodcuts, and Charts. Demy 8vo, los. 6d. 



PROFESSOR MARTIN. 



MARTIN'S ATLAS OF OBSTETRICS AND GYN^- 
^^^ COLOGY. Edited by A. Martin, Docent in the University 
of Berlin. Translated and edited with additions by Faticourt 
Barnes, M.D., M.R.C.P., Physician, to the Chelsea Hospital ; 
Obstetric Physician to the Great Northern Hospital ; and to 
the Royal Maternity Charity of London, &c. Medium 4to, 
Morocco half bound, 31s. 6d. net. 



J. F. MEIGS, M.D. 

Consulting Physician to the Children's Hospital, Philadelphia. 



AMD 



W. PEPPER, M.D. 

Lecturer on Clinical Medicine in the University of Pennsylvania. 

A PRACTICAL TREATISE ON THE DISEASES 
OF CHILDREN. Seventh Edition, revised and enlarged 
roy. 8vo, 28s. 



14 Ofttalogoe of Works 



WILLIAM MARTINDALE, F.G.8. 

Late Eztminer of the Phannaceatical Society, and late Teacher of Pharmacy 
and Demoiittrator of Materia Medica at University College. 

AND 

W. WYNN WE8TC0TT, M.B. LOND. 

Deputy Coroner for Central Middlesex. 
THE EXTRA PHARMACOPCEIA of Unofficial Drugs and 
^ Chemical and Pharmaceutical Preparations. With References 
to their Use abstracted from the Medical Journals, and a Thera- 
peutic Index of Diseases and Symptoms. Third Edition, revised 
with numerous additions, limp roan, med. 24mo, 7s. 

INow ready. 



WM. JULIUS MICKLE, M.D., M.R.C.P. 

Member of the Medico-Ptychological Association of Great Britain and Ire- 
land ; Member of the Clinical Society. London ; Medical Superintendent, 

GroTf Hall Asyinm, London. 

QENERAL PARALYSIS OF THE INSANE. 8vo, los. 



T 



KENNETH W. MILLIGAN, B.A. CANTAB., M.R.a8. 

HE EVOLUTION OF MORBID GERMS : A Contri- 
bution to Transcendental Pathology. Cr. 8vo, 38. 6d. 



STEPHEN MONCKTON, M.D., F.R.C.P. 

rpHE METAPHYSICAL ASPECT OF NATURAL 
'- HISTORY. Illustrations, imp. z6mo, 2S. 



E. A. MORSHEAD, M.R.C.S., LR.C.P. 

Assistant to the Professor of Medicine in University College, London. 

TABLES OF THE PHYSIOLOGICAL ACTION OF 
'■' DRUGS. Fcap. 8vo, is. 



A. STANFORD MORTON, M.B.. F.R.CS. ED. 

Senior Assistant Surgeon, Royal South London Ophthalmic Hospital. 

D EFRACTION OF THE EYE J Its Diagnosis, and the 
'■^'^ Correction of its Errors, with Chapter on Keratoscopy. 
Second Edition. Small 8vo, 2s. 6d. 



Published by H. K. Lewis. 16 



WILLIAM MURRELL, M.D., F.R.C.P. 

Lecturer on Materia Medica and Therapeutics at Westminster Hospital; 
Examiner in Materia Medica in the University of Edinburgh. 



WHAT TO DO IN CASES OF POISONING. Fourth 
"' Edition, revised and enlarged, royal 32mo, 38. 6d. 

II. 

NITRO-GLYCERINE AS A REMEDY FOR ANGINA 
PECTORIS. Crown 8vo, 38. 6d. 



WILLIAM NEWMAN, M.D., F.R.C.8. 

Surgeon to the Stamford Infirmary. 

CURGICAL CASES: Mainly from the Wards of the 
^ Stamford, Rutland, and General Infirmary, dvo, paper 
boards, 4s. 6d. 



DR. FELIX VON NIEMEYER. 

Late Professor of Pathologv and Therapeutics ; Director of the Medical Clinic 

of the University of Tubingen. 

A TEXT-BOOK OF PRACTICAL MEDICINE, WITH 
PARTICULAR REFERENCE TO PHYSIOLOGY AND 
PATHOLOGICAL ANATOMY. Translated from the Eighth 
German Edition, by special permission of the Author, by George 
H. Humphrey, M.D., and Charles E. Hackley, M.D. Revised 
Edition, 2 vols., large 8vo, 368. 



C. F. OLDHAM, M.R.G.S., LR.G.P. 

Surgeon H.M. Indian Forces ; late in Medical charge of the Dalhousie 

Sanitarium. 

WHAT IS MALARIA? AND WHY IS IT MOST 
INTENSE IN HOT CLIMATES ? An explanation of 
the Nature and Cause of the so-called Marsh Poison, with 
the Principles to be observed for the Preservation of Health in 
Tropicai Climates and Malarious Districts. Demy 8vo, 7s. 6d. 



16 Catalogae of Works 



a OLIVERi M.D., M.R.C.P. 

I. 
THE HARROGATE WATERS: Data Chemical and 
'' Therapeutical, with notes on the Climate of Harrogate. 
Addressed to the Medical Profession. Crown 8vo, with Map of 
the Wells, 38. 6d. 

II. 
QN BEDSIDE URINE TESTING : a Clinical Guide to 
^ the Observation of Urine in course of Work. Third Edit., 
considerably enlarged, fcap. 8vo, 3s. [y^st published 



JOHN 8. PARRY, M.D. 

Obstetrician to the Philadelphia Hospital, Vice-President of the Obstetrical 
and Pathological Societies of Philadelphia, &c. 

rXTRA-UTERINE PREGNANCY ; Its Causes, Species, 
*^ Pathological Anatomy, Clinical History, Diagnosis, Prog- 
nosis and Treatment. 8vo, 8s. 



E. Randolph peaslee, m.d., lld. 

Late Professor of Gynaecology in the Medical Department of Dartmouth Col- 
lege ; President of the New York Academy of Medicine, &c., &c. 

nVARIAN TUMOURS: Their Pathology, Diagnosis, and 
^ Treatment, especially by Ovariotomy. Illustrations, roy. 
8vo, i6s. 

G. Y. POORE, M.D., F.R.G.P. 

Professor of Medical J urispnipence, University College; Assistant Physician 
and Physician m charge of the Throat Department of University 

College Hospital. 

T ECTURES ON THE PHYSICAL EXAMINATION 
^ OF THE MOUTH AND THROAT. . With an appendix 
of Cases. 8vo, 3s. 6d. 



R. DOUGLAS POWELL, M.D., F.R.C.P., M.R.C.8. 

Physician to the Hospital for Consumption and Diseases of the Chest at 
Brompton, Physician to the Middlesex Hospital. 

niSEASES OF THE LUNGS AND PLEURA. 

•^ Third Edition, re-written and enlarged, with Illustrations, 

8vo, [/» the press, 

C. H. RALFE, M.A., M.D. CANTAB., F.R.C. P. LOND. 

Assistant Physician to the London Hospital; late Senior Physician to the 

Seamen's Hospital, Greenwich. 

l^ISEASES OF THE KIDNEY AND MORBID 

•^ CONDITIONS OF THE URINE DEPENDENT ON 

FUNCTIONAL DERANGEMENTS. Illustrations, crown 8vo. 

ewts's Practical Series^, [/„ f^g press. 



Published by H. K. Lewis. 17 



AMBROSE L RANNEY, A.M., M.D. 

Adjunct Professor of Anatomy in the University of New York, &c. 

»THE APPLIED ANATOMY OF THE NERVOUS 

^ SYSTEM, being a study of this portion of the Human 
Body from a stand-point of its general interest and practical 
utility, designed for use as a Text-book and a work of Reference. 
With 179 Illustrations, 8vo, 20s. 



H. A. REEVES, F.R.C.S. ED. 

Senior Assistant Sureeon and Teacher of Practical Sargeiy at the London 
Hospital ; Surgeon to the Royal Orthopedic Hospital, &c. 

BODILY DEFORMITIES AND THEIR TREAT- 
MENT : A Handbook of Practical Orthopaedics. With 
numerous Illustrations, crown 8vo, 8s. 6d. INow ready. 

JLewis*s Practical Series] . 



RALPH RICHARDSON^ M.A., M.D. 

Fellow of the College of Physicians, Edinburgh. 

AN THE NATURE OF LIFE : An Introductory Chapter 
^ to Pathology. Second Edition, revised and en^rged, 
Fcap. 4to, los. 6d. 



W. RICHARDSON, M.A., M.D., M.R.C.P. 

REMARKS ON DIABETES, ESPECIALLY IN RE- 
FERENCE TO TREATMENT. Demy 8vo, 2S. 6d. 



SYDNEY RINQER, M.D., 

Professor of the Principles and Practice of Medicine in University College ; 
Physician to, and Professor of Clinical Medicine in, University 

College Hospital. 

^ I. 

HANDBOOK OF THERAPEUTICS. Eleventh Edition, 
revised, 8vo. [/ft the press. 

II. 

ON THE TEMPERATURE OF THE BODY AS A 
MEANS OF DIAGNOSIS AND PROGNOSIS IN 
PHTHISIS. Second Edition, small 8vo, 2s. 6d. 



18 Catalogue of Works 



FREDERICK T. ROBERTS, M.D., B.SC., F.R.G.P. 

Examiner in Medicine at the Royal College of Surgeons ; Professor of Thera- 
peutics in University College ; Physician to University College Hospital ; 
Physician to the mompton Consumption Hospital, &c 

X. 

A HANDBOOK OF THE THEORY AND PRACTICE 
OF MEDICINE. Sixth Edition, with Illustrations, in 
one volume, large 8vo, 2 is. {.y^st published. 



N 



11. 

OTES ON MATERIA MEDICA AND PHARMACY. 

Fcap. 8vo, 7s. 6d. [Now ready. 



D. B. ST. JOHN ROOSA, M.A., M.D. 

Professor of Diseases of the Eye and Ear in the University of the City of New 

York ; Surgeon to the Manhattan Eye and Ear Hospital ; Consulting 

Surgeon to the Brooldyn Eye and Ear Hospital, &c., &c. 

A PRACTICAL TREATISE ON THE DISEASES OF 
THE EAR, including the Anatomy of the Organ. Sixth 
Edition, Illustrated by wood engravings and chromo-lithographs, 
large 8vo, 25 s. 



W. H. 0. SANKEY, M.D. LOND., F.R.C.P. 

Late Lecturer on Mental Diseases, University College, and School of Medi- 
cine, London ; Formerly Medical Superintendent (Female Department) of 
Hanwell Asylum ; President of Medico-Psychological Society, &c. 

T ECTURES ON MENTAL DISEASE. Second Edi- 
^ tion, with coloured plates, Svo, 128. 6d. [Now ready. 



ALDER SMITH, M.B. LOND., F.R.C.S. 

Resident Medical Officer, Christ's Hospital, London. 

T> INGWORM : ITS DIAGNOSIS AND TREATMENT. 
**• Third Edition, rewritten and enlarged, fcap. 8vo. 

[In the press. 



Published by H. K. Lewis. 19 



J. LEWIS SMITH, M.D. 

Physician to the New York Infants' Hospital ; Clinical Lecturer on Diseases 
of Children in Bellevue Hospital Medical College. 

A TREATISE ON THE DISEASES OF INFANCY 
-"- AND CHILDHOOD. Fifth Edition, with Illustrations, 
large Svo, 21s. 



FRANCIS W. SMITH, M.B., B.8. 



THE LEAMINGTON WATERS: Chemically, Thera- 
^ peutically, and Clinically Considered ; with Observations 
on the Climate of Leamington. With Illustrations, crown Svo, 
2s. 6d. 



JAMES STARTIN, M.B., M.R.G.8. 

Surgeon and Joint Lecturer to St. John's Hospital for Diseases of the Sldn. 

LECTURES ON THE PARASITIC DISEASES OF 
THE SKIN. Vegetoid and Animal. With Illustrations, 
crown Svo, 38. 6d. 



LEWIS A. STIMSON, B.A., M.D. 

Bbyterian Hospital; Professor of Path( 
the Medical Faculty of the University of the City of New York. 



Surgeon to the Pres^erian Hospital ; Professor of J*athological Anatomy in 

* ' " of Nei 



A MANUAL OF OPERATIVE SURGERY. With 
-^ three hundred and thirty-two Illustrations. Post Svo, 
106. 6d. 



, HENRY R. SWANZY, A.M., M.B., F.R.G.S.I. 

Examiner in Ophthalmic Surgery University of Dublin ^ Surgeon to the 

National Eye and Ear Infirmary, Dublin ; Ophthalmic Surgeon 

to the Adelaide Hospital, Uublin. 

HANDBOOK OF DISEASES OF THE EYE AND 
THEIR TREATMENT. Illustrated with Wood En- 
gravings. Colour Tests, etc., large post Svo, zos. 6d. INow ready ^ 



20 Catalogue of Works 



HUGH OWEN THOMAS, M.R.C.8. 

I. 

niSEASES OP THE HIP, KNEE, AND ANKLE 
^ JOINTS, with their Deformities, treated by a new and effi- 
cient method. With an Introduction by Rushton Parkbr, 
F.R.C.S., Lecturer on Surgery at the School of Medicine, 
Liverpool. Second Edition, 8vo, 25s. 

XI. 

CONTRIBUTIONS TO MEDICINE AND SURGERY: 

Part z. — Intestinal Obstruction ; with an appendix on the Ac- 
tion of Remedies. los. 

„ 2. — The Principles of the Treatment of Joint Disease, 
Inflammation, Anchylosis, Reduction of Joint De- 
formity, Bone Setting. 5s. 

11 5» — On Fractures of the Lower Jaw. is. 

„ 8. — The Inhibition of Nerves by Drugs. Proof that In- 
hibitory Nerve-Fibres do not exist, is. 

(Parts 3 1 4, 6, 7, 9, 10, are expected shortly). 



J. ASH BURTON THOMPSON, M.R.C.S. 

TREE PHOSPHORUS IN MEDICINE WITH SPE- 
-■• CIAL REFERENCE TO ITS USE IN NEURALGIA. 
A contribution to Materia Medica and Therapeutics. An account 
of the History, Pharmaceutical Preparations, Dose, Internal 
Administration, and Therapeutic uses of Phosphorus; with a 
•Complete Bibliography of this subject, referring to nearly 200 
works upon it. Demy 8vo, 7s. 6d. 



J. C. THOROWQOOD, M.D. 

Assistant Phjrtician to the City of London Hospital for Diseases of the Chest 

fHE CLIMATIC TREATMENT OF CONSUMPTION 
^ AND CHRONIC LUNG DISEASES. Third Edition, 
S>6st 8vo, 38. 6d. 



Published by H. K. Lewis. 21 



EDWARD T. TIBBIT8, M.D. LOND. 

Physician to the Bradford Infirmary and to the Bradford Fever Hoepital. 

IfEDICAL FASHIONS IN THE NINETEENTH 
-^ CENTURY: including a sketch of Bacterio-Mania and 
the Battle of the Bacilli. Crown 8vo, as. 6d. 



LAURENCE TURNBULL, M.D., PH.G. 

Aural Surgeon to Je£fersQn Medical College Hospital, &c., &c. 

A RTIFICI AL ANESTHESIA : A Manual of Anaesthetic 
'^ Agents, and their Employment in the Treatment of Disease 
Second Edition with Illustrations, crown 8vo, 6s. 



W. H. VAN BUREN, M.D., LLD. 

Professor of Surgery in the Bellevue Hospital Medical College. 

T)ISEASES OF THE RECTUM: and the Surgery of the 
-^ Lower Bowel. Second Edition, with Illustrations, 8vo, 
148. 



RUDOLPH YIRCHOW, M.D: 



Professor in the University, and Member of the Academy of Sciences of 

Berlin, &c. 

TNFECTION-DISEASES IN THE ARMY, chiefly 
■*■ Wound Fever, Typhoid, Dysentery, and Diphtheria. 
Translated from the German by John James, M.B., F.R.C.S. 
Fcap. Svo, IS. 6d. 



ALFRED YOQEL, M.D. 

Professor of Clinical Medicine in the University of Dorpat, Russia. 

A PRACTICAL TREATISE ON THE DISEASES 
OF CHILDREN. Translated and Edited by H. Raphael, 
M.D. From the Fourth German Edition, Illustrated by six 
lithographic plates part coloured, large Svo, iSs. 



22 Catalogne of Worlcs 



A. DUNBAR WALKER, M.D., CM. 

mHE PARENTS' MEDICAL NOTE BOOK. 
*^ Oblong post 8vo, cloth, zs. 6d. 



JOHN R. WARDELL, M.D., F.R.C.P. 

Couolting Physician to Tanbridge Wells General Hospital. 

fJONTRIBUTIONS TO PATHOLOGY AND THE 
^ PRACTICE OF MEDICINE. Medium 8vo. [J» the press. 



A. DE WATTEYILLE, M.A., M.D., B.8C., M.R.C.8. 

Physician in Charge of the Electro-therapeutical Department of St. Mary's 

Hospital. 

A PRACTICAL INTRODUCTION TO MEDICAL 
ELECTRICITY. Second Edition, re-written and en- 
larged, copiously Illustrated, 8vo, gs. 



W. SPENCER WATSON, F.R.C.&, M.B. 

Surgeon to the Great Northern Hospital ; Surgeon to the Royal South London 

Ophthalmic Hospital. 

I. 

'TYEBALL TENSION: its Effects on the Sight and its 
^ Treatment. With Woodcuts, post Svo, 2S. 6d. 

II. 

TklSEASES OF THE NOSE AND ITS ACCESSORY 

^ CAVITIES. Profusely Illustrated, demy Svo, i8s. 

III. 

AN ABSCESS AND TUMOURS OF THE ORBIT. 
^ Post Svo, 28. 6d. 



FRANCIS WELCH, F.R.C.S. 

Surgeon-Msjor, A.M.D. 



TJNTERIC FEVER: its Prevalence and Modifications; 
J-* Etiology ; Pathology and Treatment ; as illustrated by 
Army Data at Home and Abroad. Demy Svo, 58. 6d. 



Published by H. E. Lewis. 23 



DR. F. WINCKEL 

Formerly Professor and Director of the Gynecological Clinic at the Univer- 
sity of Rostock. 

fTHE PATHOLOGY AND TREATMENT OF CHILD- 
-^ BED. A Treatise for Physicians and Students. Trans- 
lated from the Second German Edition, with many additional 
notes by the Author, by J. R. Chadwick, M.D. 8vo, 14s. 



EDWARD W0AKE8, M.D. 



Senior Aural Surgeon and Lecturer on Aural Surgery at the London Hospital ; 
Senior Surgeon to the Hospital for Diseases of the Throat. 

ON DEAFNESS, GIDDINESS, AND NOISES IN 
THE HEAD. 

Part I.— POST-NASAL CATARRH, AND DISEASES 
OF THE NOSE CAUSING DEAFNESS. With Illus- 
trations, crown 8vo, 6s. 6d. 

Part II.— ON DEAFNESS, GIDDINESS, AND NOISES 
IN THE HEAD. Third Edition, with Illustrations, crown 
8vo. [/« preparation* 



E. T. WILSON, B.M. OXON., F.R.C.P. LOND. 

Physician to the Cheltenham General Hospital and Dispensary. 

TVISINFECTANTS AND HOW TO USE THEM. 
^ In Packets of one doz. price is. 



CLINICAL CHARTS FOR TEMPERATURE OBSERVATIONS, ETC. 
Arranged by W. Rigden, M.R.C.S. Price 7s. per 100, or 
IS. per doz. 

Each Chart is arranged for four weeks, and is ruled at the back for making 
notes of cases ; they are convenient in size, and are suitable both for hospitiu 
and private practice. 



M Periodical Works. 



PERIODICAL WORKS PUBLISHED BY H. K. LEWIS. 

THE NEW SYDENHAM SOCIETTS PUBLICATIONS, Annual Sub- 
■cripcion, One Guinea. 

(Report of the Society, with Complete Liet of Woiln and other information, 

gratii^jOtt application). 

THE NEW YORK MEDICAL JOURNAL. A Weekly Reriew of Medi- 
cine. Annual Subecription, One'Ci^inefifKMt free. 

ARCHIVES OF PEDIA TRICS. A Monthly Journal, devoted to the Diseases 
of Infants and Children. Annual Subscnpiion, in. 6d., post free. 

MEDICAL BULLETIN. A M^iMUy Journal of Medicine and Suxseiy. 
Edited by Dr. J. V. Shoemaker j^ 'Anual Subscntion, 5s. 

THE THERAPEUTIC .GAZETTE. A Monthly Journal, devoted to the 
Science of Phanna<dQloi5^, and to the introduction of New Therapeutic 
Agents. Edited by Drs. H. C. Wood and R. M. Smith. Annual Sub- 
scription, zos., post free. 

THE GLASGOW MEDICAL JOURNAL. Published Monthly. Annual 
Subscription, aos., post fr«e. Single numbers, 2s. each. 

LIVERPOOL MEDICO-CHIRURGICAL JOURNAL, including the Pro- 
ceedings of the Liverpool Medical Institution. Published twice yearly, 
3s. 6d. each number. 

THE MIDLAND MEDICAL MISCELLANY AND PROVINCIAL 
MEDICAL JOURNAL. Annual Subscription, 7s. 6d., post free. 

TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF PHILA- 
DELPHIA. Volumes I. to VI., now ready, 8vo, zos. 6d. each. 

THE INDIAN MEDICAL JOURNAL. A Journal of Medical and Sani- 
tary Science B|>ecially devoted to the Interests of the Medical Services. 
Annual Subscription, a4S«, post free. 



%* Mr. Lewis has transactions with the leading publishing 
firms in America for the sale of his publications in that country. 
Arrangements are made in the interests of Authors either for 
sending a number of copies of their works to the United States, 
or having them reprinted there, as may be most advantageous. 

Mr. Lewis's publications can be procured of any bookseller in 
any part of the world. 



London : Printed by H. K. Lewis, Gtmer Strut, WJC. 



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